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DEPARTMENT OF POPULATION, FAMILY AND 
REPRODUCTIVE HEALTH 
SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA 
DETERMINANTS OF ADHERENCE AND TREATMENT 
OUTCOMES AMONG ADOLESCENTS LIVING WITH HIV IN 
CAMEROON 
BY 
MBUWIR CHARLOTTE BONGFEN 
(10600726) 
THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, 
LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR 
THE AWARD OF PHD DEGREE IN PUBLIC HEALTH 
JULY 2019 
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DECLAR\TIO' 
I hereby declare that this thesis is the product of my original independent resean:h wnuw:leJ 
in selected health facilities in the North West and South West Regions of Cameroon under the 
supervision of Professor Kwasi Torpey, Professor Augustine Ankomah, and Dr. John Ganle. I 
confirm that this thesis has not been published or submitted to any institution lor any academic 
award. All references made to other researchers' works have been duly acknowledged. 
Mbuwir Charlotte Bongfen 4.::f (D  ~\ bl.Dt2D 
(PhD Candidate) Date Signature 
TEA,\1 OF Sl!PERVISORS 
Professor Kwasi Torpey 
(Principal Supervisor) Date Signature 
Professor Augustine Ankomah 
( Co-Supervisor) Date Signature 
Dr Ganle john 
(Co-Supervisor) 
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DEDICATION 
This piece of work is dedicated to all adolescents who are HlV positive. It is also dedicated 
to my daughters Sunjo Brielle Kefiyki and Sunjo Kendra Vernyuy, my dear husband Dr. 
Tata Emmanuel Sunjo, my parents; Mbuwir Abel Kavwo and Yunkung Flora Bonglam, and 
my Sister; Mbuwir Brida Verwiyni. 
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ACKNOWLEDGEMENTS 
My heartfelt gratitude goes to my supervisors Professor Kwasi Torpey, Professor Augustine 
Ankomah, and Dr John Ganle, for their support and professional directives that have seen 
the completion of this work. 
My sincere gratitude also goes to the lecturers of the School of Public Health and the 
Department of Population, Family and Reproductive Health, in particular, for the knowledge 
and academic guidance I have received from them throughout my study period. 
I am also indebted to the European Union for their scholarship award through the Partnering 
for Health Professional Training in Africa (P4HPT) project. It is thanks to the financial 
assistance from this scholarship programme that I was able to enrol and complete the PhD 
programme in the School of Public Health at the University of Ghana. 
Special thanks to all the adolescents who participated in this study. I also acknowledge with 
profound gratitude my research assistants, Wam Joel and Bessong Sarriete. My gratitude 
also goes to Kidzeru Therese (Aunty Yaya), Banin Rosette, Atanga Anye Louis and Tankoh 
Marceline for their sacrifices and efforts throughout the data collection period. 
My appreciation also goes to my sister, Mbuwir Brida, for all her support throughout my 
study period. I also accord sincere thanks to my husband, Dr. Tata Emmanuel Sunjo; my 
children. Sunjo Brielle and Sunjo Kendra; my parents, Mbuwir Abel and Yunkung Flora, 
the Yunkungs Family, the Badzi's family and all my friends for their moral support 
throughout my study and stay in Ghana. 
Finally, I am most grateful to the Almighty God for all the wonderful things he has done 
and continues to do in my life. 
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TABLE OF CONTENTS 
DECLARATION ..................... . .............................. . ................................ 
DEDICATION ............................ ....... . ............................. . .. ............................. ii 
ACKNOWLEDGEMENTS ................................................ . . .................................. .iii 
TABLE OF CONTENTS ................... ····························· ..................................... iv 
LIST OF TABLES .............................................. . ................................... viii 
LIST OF ABBREVIATIONS ....................... .............. . .. ....................................... .x i 
DEFINITION OF KEY TERMS ............................. . . ................................... .x ii 
ABSTRACT ........................ · .... ·· .. ··· .. ·. ... · .. ·· .. ·· .. ····· ......................................... xiii 
CHAPTER ONE .......................................... ............ . ...................................... .. 
INTRODUCTION .............................................. . . ........................................................ 1 
1.0 Background ...................................... . .......................................................... 1 
1.  I Problem Statement ........................... ········ .. ...................................................... 4 
1.2 Research questions.......................... . ................................................................... 7 
1.3 Objectives............... ....................... .. ..................................................... 7 
1.3.1 General objective ...................... . .. ........................................................ 7 
1.3.2 Specific Objectives....................... . .................................................... 8 
1.4 Research Hypotheses ........................................ .................................................... 8 
1.5 Justification ................................................................................................................ 8 
1.6 Chapter summary and thesis outline ......................................................................... 10 
CHAPTER TWO ................................................................................................................ 11 
LITERATURE REVIEW ................................................................................................. 11 
2.0 Introduction ............................................................................................................... 11 
2.1 The concept of adolescence ...................................................................................... 11 
2.2 HIV and adolescence ................................................................................................. 14 
2.3 The Concept of Adherence ........................................................................................ 16 
2.4 Adherence to ART .................................................................................................... 18 
2.5 Consequences of Poor Adherence ............................................................................. 21 
2.6 Adolescents living with HIV ..................................................................................... 22 
2.7 Adherence to ARV among adolescents ..................................................................... 25 
2.8 Treatment Outcomes ................................................................................................. 27 
2.8.1 Viral load suppression ........................................................................................ 27 
2.8.2 Lost to follow up (LTFU) .................................................................................. 29 
2.8.3 Retention ............................................................................................................ 30 
2.8.4 CD4 Counts ........................................................................................................ 30 
2.8.5 Mortality ............................................................................................................. 31 
2.9 Adolescents' perspectives on HIV and ART adherence ........................................... 33 
2.10 Challenges to Adherence ......................................................................................... 34 
2.10.1 Individual factors ............................................................................................. 35 
2.10.2 Medication Factors ........................................................................................... 35 
2.10.3 Health Service factors ...................................................................................... 36 
2.10.4 Socio-economic Factors ................................................................................... 36 
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2.11 Detenninants of Adherence to Anti-Retroviral Therapy among adolescents ......... 37 
2~. :1; ~T~:~?:~~.~~":~~· ..........· •• ·· · •• ·.•:  •• • ·•·· ...••· .... .· •••• •••••••.•••••••.••..•• ~~ 
2.11 .1 .4 Distance to Health Facility ......................................... ······························· 39 
2.:i~21;~!i~~~~~:i·f~~~~;~·:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~: 
2.11.2.1 Use of traditional medicines ..................................................................... .40 
2.11.2.2 Beliefs in Spiritual Healing ...................................................................... .40 
2.11.3 Health Services and System Factors ................................................................ 41 
2.11.4 Patient factors ............................................................ ················ .. ······ .... · .. ·· .. ···· 41 
2.11.4.1 Medication related side effects ................................... ··.·· ......................... 42 
2.11.4.2 Internalized stigma .................................................................................... 45 
2.11.4.3 Other illnesses or comorbid conditions ................................................... .46 
2.11.5 Other factors ..................................................................................................... 47 
2.11.5.1 Stigma ....................................................................................................... 48 
2.11.5.2 Forgetting to take medications ................................................................. .49 
2.11.5.3 Financial constraints ................................................................................ .49 
2.11.5.4 Pill Burden ................................................................................................ 50 
2.12 Care of adolescents and health facility preparedness towards providing ART 
services ............................................................................................................................ 51 
2.12.1 Care of Adolescents with HIV at the facility level .......................................... 51 
2.12.2 Health facility preparedness in Providing ART services to adolescents with 
HIV .............................................................................................................................. 55 
2.13 Strategies to improve adherence to ART among adolescents ................................. 57 
2.14 Global Response to the HIV epidemic among adolescents .................................... 68 
2.15. Measurement issues in adherence research ............................................................ 69 
2.15.1 Self-Reporting .................................................................................................. 70 
2.15.2 Pill counts ......................................................................................................... 71 
2.15.3 Phannacy Refill Records .................................................................................. 71 
2.15.4 Therapeutic Drug Monitoring .......................................................................... 72 
2.15.5 Composite Measures ........................................................................................ 73 
2.16 Philosophical Underpinnings of the Conceptual Framework ................................. 73 
2.17 Conceptual Framework ........................................................................................... 75 
2.18 Chapter summary .................................................................................................... 77 
CHAPTER THREE ............................................................................................................. 78 
METHODS ......................................................................................................................... 78 
3.0 Introduction ............................................................................................................... 78 
3.1 Type ofStudy/Study design ...................................................................................... 78 
3.2 Study Location/Area ................................................................................................. 78 
3.2.1 Location of the study Area ................................................................................. 81 
3.2.3 Socio-Demographic Characteristics ................................................................... 83 
3.2.4 Economic Activities ........................................................................................... 84 
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3.2.5 Healthcare Services and Infrastructure .............................................................. 85 
3.7 Data Collection Methods and Tools ............................................... ········ ................... 92 
3.7.1 Data collection methods ............................................................ ····· .................... 92 
3.7.2 Data Collection tools ................................................................ · ......................... 93 
3.83~~~~=:~~~::::c~~i~~~~·::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~~: 
3.8 2 Pre-testing of questionnaire ............................................................................. 105 
3.9 Data entry and processing ......................................................... ·.·.·· .. · .... ·· ............... 105 
3.10 Variables and measurement .................................................................................. 105 
3.10.1 Adherence ...................................................................................................... 106 
3.10.2 Treatment outcomes ........................................................... ··.· .. ···· .................. 10 6 
3.10.3 Patient factors ........................................................................... ·· .................... 107 
3. t 0.4 Health Service factors .................................................................................... 108 
3.10.5 Socio-cultural factors ..................................................................................... 108 
3.10.6 Demographic factors ...................................................................................... 108 
3.10.7 Other factors ................................................................................................... 109 
3.10.8 Statistical Methods ......................................................................................... 109 
3.11 Ethical Considerations/Issues ................................................................................ 110 
3.11.1 Administrative and Ethical Approval.. ........................................................... 110 
3. t 1.2 Informed consent. ........................................................................................... 111 
3.11.3 Informed ascent. ............................................................................................. 111 
3.11.4 Confidentiality ............................................................................................... 112 
3.11.5 Privacy ........................................................................................................... 112 
3.11.6 Benefits .......................................................................................................... 112 
3.11.7 Risks ............................................................................................................... 112 
3.11.8 Right to withdraw ........................................................................................... 113 
3.12 Chapter Summary .................................................................................................. 113 
CHAPTER FOUR ............................................................................................................ 114 
RESULTS ........................................................................................................................ 114 
4.0 Introduction ............................................................................................................. 114 
4.1 Demographic Characteristics of Participants .......................................................... 114 
4.2 Clinical Characteristics ........................................................................................... 116 
4.3 Trends in yearly enrolment of participants into treatment ...................................... 118 
4.4 Distribution of Adolescents by Facility .................................................................. 119 
4.5 ARV Adherence levels ............................................................................................ 120 
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4.5.1 Self- Report ARV Adherence .......................................................................... 120 
4.5.2 Medication Possession Ratio (MPR) .............................................................. 120 
4.6 Detenninants of Adherence .................................................. ·. ... ·· ............................ 122 
4.6.1 Socio-demographic factors and Adherence ..................................................... 122 
4.6.2 Health Service factors ...................................................................................... 125 
4.3.3 Socio-cultural factors and Adherence .............................................................. 126 
4.6.4 Patient Factors and Adherence ......................................................................... 128 
4.6.5 Other factors of Adherence .............................................................................. 131 
4.7 Multivariate analysis of the determinants of adherence ........................... · .......... ·· .. 132 
4.8 Detenninants of both self-report and the Medication Possession Ratio adherence 135 
4.9 Challenges of Adherence among Adolescents ........................................................ 135 
4.10 Improving Adherence among Adolescents ........................................................... 137 
4.11 Adolescents HIV Treatment Outcomes ................................................................ 139 
4.11.1 Measures of viral load ....................................... · .. · ...... · .......... · ...... · .... """. ..... 139 
4.11.2 Relationship between Adherence and Viral load ........................................... 140 
4.12 CD4 Measurements ............................................................................................... 140 
4.13 Retention rates .................................................................... · .. ·········· ...................... 141 
4.13.1 Retention rates at six months ......................................................................... 142 
4.13.2 Retention Rates at 12 months .......................................... · ...... · ...................... 143 
4.13.3 Retention Rates at 24 months ......................................................................... 144 
4.14 Facility Preparedness towards Care of Adolescents ............................................. 146 
4.14.1 Adherence by Health Facility Score .............................................................. 149 
4.15 Chapter Summary .................................................................................................. 150 
CHAPTER FIVE ............................................................................................................... 151 
DISCUSSION ................................................................................................................... 151 
5.0 Introduction ............................................................................................................. 151 
5.1 Clinical characteristics of participants .................................................................... 151 
5.2 Adherence level among adolescents ....................................................................... 152 
5.3 Detenninants of adherence among adolescents ...................................................... 154 
5.4 Challenges of Adherence in adolescents ................................................................. 163 
5.5 Adolescent's perspective on adherence .................................................................. 166 
5.6 Improving adherence among adolescents ............................................................... 168 
5.7 Treatment outcomes among adolescents with HIV ................................................ 170 
5.8 Facility preparedness towards care of adolescents ................................................. 172 
~11~§~;£tl~~::::::::::::::::::::::::::··:···:::·::::::::::::::::::::::::::::::::::::::::::::: m 
~~~~~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~~~ 
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LIST OF TABLES 
Table 1 Recommendations for starting ARVs in adolescents and Adults in Cameroon .... 55 
Table 2 Number of Adolescents on treatment in the selected Health Facilities ................. 91 
Table 3: Scoring Summary of the lSI Too!... .................................. ···.············ .................. 104 
Table 4: The Kappa benchmark scale ............................................................................... 110 
Table 5: Socio-demographic Characteristics of Participants ............................................ 115 
Table 6 Clinical Characteristics of Participants by Sex .................................................... 117 
Table 7 ARV drug types used by participants with their code names .............................. 118 
Table 8 Relationship between Self-Report adherence measure and 
Medication Possession Ratio ., .................................................................................. 122 
Table 9 Relationship between adherence and socio-demographic factors ........................ 124 
Table 10: Health Service Factors and Adherence ............................................................. 126 
Table II Relationship between Socio-cultural factors and Adherence among Adolescents. 127 
Table 12 Relationship between Patient Factors and Adherence ....................................... 130 
Table 13: Other Determinants of Adherence .................................................................... 131 
Table 14 Relationship between Adherence and its Detem1inants in Multiple 
Logistic Regression Analysis .................................................................................... 133 
Table 15: Determinants of both self-report and the Medication Possession Ratio adherence 136 
Table 16 Challenges of Adherence faced by the Adolescents .......................................... 137 
Table 18 Relationship between Viral load suppression and Adherence ........................... 140 
Table 19 Relationship between Adherence and CD4 among adolescents ........................ 141 
Table 20 Retention rates at 6 months ................................................................................ 142 
Table 21: Retention Rates at 12 months ........................................................................... 143 
Table 22: Retention Rates at 24 months ........................................................................... 145 
Table 23: Health Facility Readiness to provide care to adolescents ................................. 147 
Table 24: Health Facility Score and Interpretation of Score ............................................ 149 
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LIST OF FIGURES 
Figure 1: New HIV infections globally 2000-2016 among Adolescents (1 0-19 years) ..... 23 
Figure 2. Global distribution of number of adolescents aged 10-19 years living 
with HIV by country in 2014 ...................................................................................... 24 
Figure 3. Proportion of adolescents aged 10 - 19 living with HIV. by selected 
high-burden countries 2014. ........................................................................................ 24 
Figure 4: Total AIDS related deaths and deaths in adolescents .......................................... 31 
Figure 5: Conceptual framework ........................................................................................ 76 
Figure 6. Map of Cameroon showing North West and South West Regions ..................... 79 
Figure 7: Map of the North West and South West Regions showing the Study Sites 
within the Health Districts .......................................................................................... 82 
Figure 8: The distribution of adolescents by year enrolled into treatment ....................... 119 
Figure 9: Participant distribution according to health facility .......................................... 119 
Figure 10: Percentage distribution of participants by Self-Report Adherence ................. 120 
Figure II: Adolescents Adherence levels using the MPR Measure ................................. 121 
Figure 12: Participant's perspective on improving adherence .......................................... 138 
Figure 13: Viral load suppression among Adolescents ..................................................... 139 
Figure 14: Measures ofCD4 count ................................................................................... 141 
Figure 15: Retention rates per Health Facility .................................................................. 145 
Figure 16: Adherence by Facility Score ............................................................................ 150 
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LIST OF APPENDICES 
Appendix I: Invitation to Participate in PhD Research .................................................... 202 
Appendix 2: Participant Information Sheet for adolescents at least 18years .................... 203 
Appendix 3: Written consent form for Adolescents at least 18years ................................ 204 
Appendix 4: Infonnation sheet for Guardian .................................................................... 205 
Appendix 5: Written Consent form for Guardian ............................................................. 207 
Appendix 6: Information Sheet for adolescents less than 18years ................................... 208 
Appendix 7: Written assent form for Adolescents less than 18years ................................ 210 
Appendix 8: Questionnaire ............................................................................................... 211 
Appendix 9: Data Extraction form for Adolescents on ARV treatment ........................... 218 
Appendix 10: Research Approval Letter from the North West Regional Delegation 
of Public Health ......................................................................................................... 222 
Appendix 11: Research Approval Letter from the West West Regional Delegation 
of Public Health ......................................................................................................... 223 
Appendix 12: Ethical Approval Letter from Cameroon Baptist Convention 
Institutional Review Board ...................................................................................... 224 
Appendix 13: Letter of Support for Ethical Clearance Application ................................. 226 
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LIST OF ABBREVIATIONS 
ACTG AIDS Clinical Trial Group 
ALHIV Adolescents Living with HIV 
ART Antiretroviral Therapy 
ARV Anti -retroviral 
BBH Banso Baptist Hospital 
BHM Baptist Hospital Mutengene 
BRH Buea Regional Hospital 
BUCREP Central Bureau of Census and Population studies 
CAMPHIA Cameroon Population-Based HIV Impact Assessment 
CASE Centre for Adherence Support Evaluation 
CBC Cameroon Baptist Convention 
CBOs Community Based Organisations 
CDC Centre for Disease Control and Prevention 
HIV Human Immunodeficiency Virus 
lAS International AIDS Society 
JSI John Snow Inc 
KDH Kumba District Hospital 
LRH Regional Hospital Limbe 
LTFU Lost to Follow Up 
MIS Management Information System 
MPR Medication Possession Ratio 
NACO National AIDS Control Organisation 
NBH Nkwen Baptist Hospital 
NGOs Non-governmental Organisation 
RHB Regional Hospital Bamenda 
RTG Regional Technical Group 
SARA Service Availability and Readiness Assessment 
UNAIDS United Nations AIDS Programme 
VCT Voluntary Counselling and Testing 
WHO World Health Organisation 
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DEFINITION OF KEY TERMS 
For the purpose of this study, the key terms have been operationally defined as follows: 
Adolescents: An individual who is aged between 10-19years. 
Young adolescence: A period of an individual's life when they are aged 10-14years. 
M idd Ie adolescence: A period of an individual's life when they are aged 15-17years. 
Late adolescence: A period of an individual's life when they are aged 18-19years. 
Self-Report Adherence: The proportion of the number of pills taken to the number 
prescribed within the past 30 days. 
Viral load suppression: Having a viral load count less than 1000copies/ml of blood. 
Determinants of adherence: The factors that undermine or facilitate one's ability to take 
prescribed medication. 
Medication Possession Ratio: The sum of the days of treatment supplied for all Anti-
retroviral prescriptions filled, within the refill interval to the number of days during that 
same time interval. 
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ABSTRACT 
Background: Despite over three decades of HIV, its prevalence especially among 
adolescents remains a public health concern. In 2015, there were more than two million 
adolescents living with HIV, with a higher proportion coming from sub-Sahara Africa. In 
Cameroon, there are over 40,000 adolescents living with HIV and there are still concerns 
about the provision of care to them as adolescents are trapped between paediatric and adult 
services which are unable to address their specific needs. However, there are limited studies 
in Cameroon that have examined adherence to antiretroviral treatment and associated factors 
as well as treatment outcomes among adolescents. It is therefore essential to clearly 
understand the detenninants of adherence oft hese adolescents and their treatment outcomes. 
Objectives: The main objective of the study was to assess the determinants of adherence to 
Anti-Retroviral Therapy and treatment outcomes among adolescents living with HIV in 
Cameroon. 
Methods: The study was an analytical cross-sectional sStudy with a record review 
component. A total of 460 respondents were recruited from nine health facilities. A 
systematic random sampling procedure was used to select the required participants. Pre-
tested questionnaires were administered to participants to collect data. The main outcome 
of interest (adherence) was measured in two ways: self-report adherence, and medication 
possession ratio (MPR). Three treatment outcome measures that were assessed included 
viral load suppression, retention in treatment, and CD4 counts. Finally, health facility 
readiness towards care for adolescents on ARV was assessed using the John Snow Inc. (JSI) 
tool. Descriptive (frequencies and proportions) and inferential (chi square and multivariate 
logistic regression) statistical analyses methods were used to analyse the data. Statistical 
significance was set at p<0.05 at a 95% confidence level. 
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Results: A total of 455 questionnaires were retained and this gave a response rate of 99%. 
The average age of the adolescents was 14.8years (SD= ±2.9years). There were more 
females (55%) than males (45%) in the study. A larger proportion of the respondents were 
on first line treatment (77%) and had been on treatment for an average of five years. Self-
report adherence was 83% while MPR was 73%. The difference in adherence between self-
report and the Medication Possession ratio was not statistically significant (p=0.97). 
Regarding the determinants of adherence, 12 out of 30 independent variables examined 
showed significant statistical association with adherence at the bivariate level. In 
multivariable logistic regression analyses however, only two variables significantly 
predicted adherence, namely experiencing side effects (AOR= 2.63; 95%CI=1.14, 6.09; p = 
0.02) and internalized stigma (AOR=2.51; 95%CI =1.04, 6.04; P = 0.04). The major 
challenges to adherence were stigma (59%) and forgetfulness to take medications (59%) 
while sending reminder messages and having friendlier health providers were the main 
suggestions to help improve on adherence. In terms of treatment outcomes, 70% of the 
respondents had their viral load suppressed. The retention rates were observed to decrease 
over time: 88%, 72% and 58% at 6months, 12 months and 24 months respectively. All the 
selected facilities were shown to be ready to receive adolescents into treatment as 7 out of 
the 9 facilities were in stage 5 of the facility readiness assessment. 
Conclusion: The determinants of adherence among adolescents are more psychological than 
the physical characteristics that differentiate them. There is therefore a need for more 
individual-targeted counselling for adolescents and their guardians to improve adherence 
levels among adolescents on antiretroviral treatment. 
Keywords: Adolescents, adherence, determinants, Anti-retroviral, treatment outcomes, 
stigma, side effects, viral load suppression, retention. 
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CHAPTER ONE 
INTRODUCTION 
1.0 Background 
The 2l't Century has witnessed several epidemics on a global scale; yet HIV has been one 
of the longest and severest health challenges facing public health programmes. The United 
Nations AIDS (UNAID) estimates that in 2018, there were over 37.9 million people living 
with HIV worldwide (UNAIDS, 2019). The virus has claimed millions of lives and many 
more are infected every day. UNAID (2016) notes that despite the declining figure of new 
infections, the number of people living with HIV has continued to rise given that, many of 
the individuals living with the virus are able to lead longer and healthier lives, mostly as a 
result of effective antiretroviral therapy (ART). 
At first, HIV was considered to be a disease of adults, especially those with high risk sexual 
behaviours (horizontally transmitted) until it was realized that mothers could pass it on to 
their babies (vertical transmission). The prevention of mother-to-child transmission of HIV 
interventions became accessible in most countries in Africa around 2004 (Lowenthal et af., 
2014). From 2004 to 2017, the cohort of children who were infected through vertical 
transmission and survived together with many more who acquired the infection through 
risky sexual behaviours are now Adolescents Living with HIV (ALHIV). 
Until the early 2000s, the assumption was that, most children born to HIV positive mothers 
will not live beyond five years (Ferrand et al., 2009). Nevertheless, a cohort study revealed 
that at least 13% of these children could survive to age 10 years, with more recent 
estimations showing that 17% of them will survive up to 15 years of age (ibid). Moreover, 
due to improvements in HIV treatment, mortality in perinatally infected children has 
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declined, thus making it possible for them to live up to adolescence even in the face of the 
challenges of taking ARVs (Palladino et aI., 2009; Edmonds et a/., 2011). 
Worldwide, there are over 3 million children infected with HIV and their survival to 
adolescence indicates that a significant number of them adds to the number of adolescents 
living with HIV (Lowenthal ef aI., 2014). UNICEF estimates that 700 adolescents are 
infected with HIV daily and if current trends remain constant, the world will be hosting over 
1.9 million adolescents living with HIV by 2030 (UNICEF. 20IS). 
Generally, young people and adolescents have been more susceptible to HIV infection. By 
June 2018, it was estimated that, out of the 37.9 million people living with HIV (PLHIV) 
worldwide, more than 90% were in the global south, with 1.7 million of them being aged 
less than ISyears (UNAIDS, 2019). Furthermore, in 2013, there were over 6300 new HIV 
infections everyday globally and about 2S00 of these were adolescents and young people 
between the aged IS-24years (WHO, 20l3a). In Cameroon, there are 6S,37S youth (IS-
24years) living with HIV and this gives a prevalence of 1.4% among this age group 
(PEPFAR, 2018a). Therefore, adolescents and youth remain susceptible to having the HIV 
infection, especially those living in settings with a generalised HIV epidemic (WHO, 
2013a). 
The prevalence ofHIV among adolescence in Cameroon was estimated to be 2% in 2015, 
with about new 4200 infections and 1900 deaths (UNICEF, 201S). As of2016, a total of 
about 40,000 adolescents were living with HIV in Cameroon (UNAIDS, 2017b). In spite of 
this, adolescents are an underserved group in global and national responses to the HIV 
pandemic. Global declarations, commitments and targets have not given attention to their 
particular needs (MacPherson et al., 2015; UNICEF, 2015). With the launching of the 
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SDGs, much of the world has focused its attention towards achieving the targets of the 
Sustainable Development Goals (SDGs), however, the HIV epidemic among adolescents is 
also a call for concern and it is imperative to hasten up efforts to curbing the epidemic. This 
is a necessary step focused on ending the HIV epidemic and ensuring that all adolescents 
have the opportunity to live on (UNICEF, 2015). 
Adolescence is a time of vibrancy. exploration and self-discovery; it is also a time of rapid 
and sometimes confusing physical, psychological and emotional changes (UNICEF., 2002). 
When this is further complicated by an infection like HIV, the adolescent may face more 
challenges than a non-infected peer. With the high number of adolescents living with HIV, 
it is imperative to understand the determinants of adherence and the treatment outcome. 
Adherence is an individual's ability to follow treatment plans, take medications at 
designated times and frequencies and follow restrictions regarding food and other 
medications correctly (Sahay, Reddy, & Dhayarkar, 2011a). Moreover, adherence could 
also be an individual's ability to follow-up all clinic visits (WHO, 2010). 
Globally, adherence has been estimated to be lower in adolescents than in other age groups 
(Sung-Hee, Gerver, Fidler, & Ward, 2014). A systematic review by Sung-Hee and others in 
2014, reported adherence in adolescents to be 62.3% (Sung-Hee et al., 2014). The treatment 
of HIV is long and could even last a life time and adherence to medication has been shown 
to reduce with time. All HIV patients are on daily medication and the process is difficult 
and monotonous such that after six months, adherence to the medications begin to drop as 
shown in a study by Nsheha and others in 2014 (Nsheha, Dow, Kapanda, Hamel, & Msuya, 
2014). 
Worldwide. issues of adolescent health are gradually attracting concern and in the case of 
ALHIV, health facilities are preparing to have the adequate resources to enable them provide 
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care to these HIV positive adolescents. Scaling up of HIV care in developing countries is 
usually very challenging as it requires increases in terms of infrastructure, human resources 
and limited drug management systems (Mapunjo, 2007). These factors could possibly affect 
adherence especially in the case of adolescents who need to be given special attention. 
Generally, non-adherence increases the chances of virologic failure by 50%, and viral 
resistance also reduces the effectiveness of treatment, thereby causing the disease to advance 
and may decrease treatment options in the near future as well as increase the possibility of 
disease transmission as a result of unsuppressed viral loads (Roux et ai., 2011). Hence, 
optimal adherence, that is, greater than 95% of pills taken is the key to success in HIV 
infected children and adolescents who are on long term treatment (Shah, 2007; Arage, 
Tessema, & Kassa, 2014). It is for this reason that the current study aimed to assess treatment 
adherence, and the factors that determine treatment adherence and outcomes among 
adolescents living with HIV in Cameroon. 
1.1 Problem Statement 
Despite over three decades of HIV, its prevalence especially among adolescents remains a 
public health concern. By 2017, there were over 250,000 new HIV infections among 
adolescents globally with a higher proportion living in sub-Sahara Africa (UNAIDS, 2019). 
In Cameroon, UNICEF estimated over 4200 new HIV infections in adolescents by 2015 
and by 2016, there were over 40,000 adolescents who had HIV (UNICEF, 2018). In 2012, 
the prevalence of HIV among adolescents in Cameroon was 2%, and 4000 new infections 
are anticipated to OCcur annually (UNICEF, 2015). The rising number of HIV positive 
adolescents is perhaps due to the increase in incidence of horizontally acquired HIV as well 
as increase in the survival rates of children who acquired the virus through mother to child 
transmission of HIV (Maskew et al., 2016). 
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Adolescents at their age are faced with challenges that are cognitive and developmental, 
emotional and sometimes family dysfunction (UNICEf., 2002). Adolescents have for some 
time been trapped between child and adult services, which do not meet up their particular 
needs. such as HIV status disclosure, adherence support mechanisms, issues of stigma and 
discrimination, sexual and reproductive health. mental healthcare, legal and social support 
(Ferrand et aI., 2009). The situation is not very different in Canleroon where there are 
thousands of adolescents living with HIV. As a result, adhering to ART treatment has 
become an important subject. 
Recent treatment protocol requires early initiation of antiretroviral treatment (ART) with 
adolescents increasingly being the most initiators of ART (MacDonell, Naar-King, Huszti, 
& Belzer, 2013). Evidence from research done on adherence to ART among adolescents has 
shown that. HIV adherence is lower than in adults (WHO, 2013a; Sung-Hee et al., 2014). 
Adherence among adults in Cameroon is above 90% (Mbuagbaw et al., 2011). However, 
adherence among adolescents in Cameroon is unknown and hence the need for the present 
study. 
Worldwide. there was a 50% rise in HNIAIDS related deaths among young people and 
adolescents between the age 1O-24years, and this indicates the need for improvements in 
HIV treatment. care and retention among this age group (Lall, Lim, Khairuddin, & 
Kamarulzaman. 2015). However, ART drugs are known for their complications with 
special dosing requirements and side effects (Brogly et al., 2005). Adolescents with HIV 
face different barriers to adherence from adults (Buchanan et al., 2012). Such barriers (Ibid) 
include health facility issues, demographic and socio-cultural factors as well as difficulties 
at the individual level. Moreover, adolescents with HIV have a higher potential for non-
adherence to ART due to their biological development which is characterized by reduced 
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inhibition, increased risk-taking, and reduced support from parents or caregiver (Reisner et 
al., 2009). The PEPF AR strategic report for Cameroon indicates that there are 17,557 youth 
receiving ARV drugs with an estimated viral load suppression of 69% (PEPFAR, 2018b). 
This lower viral load suppression is an indication that there are issues relating to adherence 
to ARV. In this regard, this study sought to assess some of the predictors of adherence, 
especially as they relate to adolescents with HIV and their adherence to ART in Cameroon. 
Some scholars have identified health service characteristics as one of the many set of factors 
that could affect ART adherence (Sung-Hee et al., 2014). In line with these scholars (Ibid), 
one of these relates to the fact that adolescent's access to health facilities is always limited 
and they are sometimes marginalised from mainstream healthcare provision. Generally, 
there is a standard level of quality of care required for the delivering antiretroviral therapy 
(WHO, 2004b: Gilks et al., 2006) and this is not different for adolescents. In fact, 
adolescents need to be given special attention. Some of the indicators that are used to 
measure how prepared a facility is in providing care for living HIV positive persons and in 
this case adolescents, include organization ofHIVI  AIDS care within the facility, availability 
of human resource and protocols, clinical HIV/AIDS care and treatment services, records 
keeping and reporting system, facility preparedness for HIV I AIDS care and treatment, 
laboratory and pharmacy services (Mapunjo & Urassa, 2007). Given that issues of 
adolescents' health in sub-Sahara Africa especially relating to HIV have only recently been 
brought to the lime light, many health facilities particularly HIV treatment centres may still 
be preparing their facilities to adequately receive adolescents with probably limited 
knowledge about adolescent care. 
Generally, adhering to ART improves treatment outcomes. Yet, few studies have 
investigated treatment outcomes in adolescents. For example, lost to follow up could mean 
the patient has stopped treatment which could lead to disease progression or drug resistance 
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in some cases and worse still death (Nabukeera-Barungi el al., 2015). In addition, retention 
in ART is one of the main target of HI V treatment programmes; however, it has been sho\W 
that adolescents are experiencing extremely poor ART outcomes compared to adults; this is 
resulting in increased mortality, loss to follow-up, and lower rates of viral load suppression 
in adolescents compared to other age groups (Bygrave et ai., 2012). Earlier studies in 
Cameroon have been focused on adults and treatment outcomes among HIV positive 
adolescents have been rarely reported (Fokam, el al., 2017). There was therefore the need 
to conduct this study to assess adherence to anti-retroviral treatment among adolescents in 
Cameroon with emphasis on the determinants, challenges and outcomes of treatment 
adherence. 
1.2 Research questions 
1. What is the level of adherence among HIV positive adolescents on treatment? 
2. What are the determinants of adherence among HIV positive adolescents? 
3. What are the challenges adolescents face adhering to treatment? 
4. What is the level of facility preparedness towards care of adolescents? 
5. What are the treatment outcomes of adolescents living with HIV? 
1.3 Objectives 
1.3.1 General objective 
The general Objective of the study was to assess the determinants of adherence to Anti-
Retroviral Therapy and treatment outcomes among adolescents living with HIV in 
Cameroon 
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1.3.2 Specific Objectives 
The specific objectives were to: 
1. Detennine the level of adherence among HIV positive adolescents who are on 
treatment. 
2. Assess the detenninants of adherence to ART among HIV positive adolescents who 
are on treatment. 
3. Investigate the challenges of adherence and strategies to improve adherence. 
4. Assess the level of facility preparedness towards care of adolescents with HIV. 
5. Evaluate treatment outcomes of adolescents living with HIV. 
1.4 Research Hypotheses 
This study was guided by the following hypotheses. 
1. The level ofa dherence among HIV positive adolescents who are on treatment is low. 
2. Adherence to ART among HIV positive adolescents who are on treatment is 
detennined by demographic and socio-cultural, health service factors. 
3. There are significant challenges to adherence to ART among HIV positive 
adolescents on treatment. 
4. The level offaciJity preparedness towards care of adolescents with HIV is low. 
5. ARV Treatment outcomes of adolescents living with HIV are low. 
1.5 Justification 
This study assessed adherence and its detenninants as well as treatment outcomes among 
adolescents living with HIV. Adherence to ART has been shown as one of the most 
significant barriers for improving health outcomes in adolescents living with HIV (Haberer 
& Mellins, 2009). Aside the therapeutic effects of ARVs, it also offers HIV prevention 
benefits, delays drug resistance, and reduces the risk ofHIV transmission to others. Factors 
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affecting adherence among this age group were studied and recommendations have been 
made, which could be used to improve treatment outcomes. 
The study also determined adolescents' views on improving adherence. This provided 
information about their expectations, beliefs and suggestions as far as their care and issues 
of adherence to ARVs are concerned. This information could be used to guide policies 
related to enhancing healthcare provision to ALHIV for better outcomes. 
Treatment outcomes among HIV positive adolescents were also measured. The treatment 
outcomes for the study included: retention, viral load suppression, CD4 response and lost to 
follow-up. This information could help bridge the gap in relation to knowledge about 
treatment outcomes in adolescents as data is unavailable for adolescents in Cameroon. This 
could further be used to inform decision making pertaining to adolescent's care. 
In addition, the study assessed facility preparedness towards care of adolescents living with 
HIV. Health facilities providing HIV services to adolescents must be adequate in terms of 
the material and human resource capacity and also the conditions in which care is provided 
such as infrastructure, equipment and staff. These include optimal patient-provider 
interactions, diagnosis, treatment, follow up and prevention activities (Donabedian, 2002). 
The study assessed the availability of space, trained personnel, treatment guidelines and 
organization of activities for adolescents with HIV. This information could be used to 
enhance decision-making given the importance of maximizing treatment outcomes of HIV 
in this age group. Finally, the findings of the study have identified gaps for further research 
in this area. 
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1.6 Chapter summary and thesis outline 
This chapter presents an introduction of the study with a background on adherence both at 
the global and local level. The chapter also provides a statement of the problem and the need 
for this study in Cameroon. The general and specific objectives of the study are also 
presented in this chapter. The other sections of the thesis are organised as follows: Chapter 
two presents literature review of published works on adherence and its determinants among 
adolescents. adherence measurement and treatment outcomes. The chapter also explains the 
conceptual framework of the study. Chapter three describes the methods and procedures of 
data collection and analysis; chapter four presents the study's findings, while chapter five 
discusses the results. The final chapter concludes and makes relevant recommendations. 
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CHAPTER TWO 
LITERATURE REVIEW 
2.0 Introduction 
This chapter presents a review of published material on adherence to ARV treatment among 
adolescents. It first describes the concept of adolescence, the effect of HIV on adolescence, 
the concept of adherence and the determinants of adherence. The chapter also provides an 
understanding of the adherence situation globally, regionally and in the Cameroonian 
context. Likewise. literature on mortality among adolescents with HIV as well as facility 
readiness towards care of adolescents is also reviewed in this chapter. The last aspect of the 
review looks at adherence measurements in various studies across globally. 
2.1 The concept of adolescence 
Adolescence, a transitional phase of growth between childhood and adulthood is defined in 
physical and cultural contexts. Whereas age defines the physical maturation, cultural 
perspectives of adolescence vary from one context to the other (UNICEF, 20 11). 
According to the World Health Organization (WHO) an adolescent is as any person between 
the ages 10 and 19. This age range is a subset to the WHO's definition of young people as 
individuals between ages 10 and 24(WHO, 2013a). Most cultures regard the cycle of 
physical changes resulting in reproductive maturity as adolescence. These societies define 
adolescence as the period between ages 12 and 20 (Sawyer, Azzopardi, Wickremarathne, & 
Patton, 2018). Adolescence experience is unique for each individual and is largely 
dependent on the individual's growing up with differences in physical development, 
emotional experiences, cognitive maturation as well as the environment (Cieslik & Pollock, 
2017). There are varied views on the various stages of the adolescence. Whereas some 
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authors suggest a two stage division(UNICEF. 2011), others suggest tbree(Blum, Mmari, & 
Moreau, 2017). However, the various suggestions are all within the age limit for the stage 
of adolescence. The stage of adolescence can be categorized into two phases; early 
adolescence and late adolescence (UNICEF, 2011) or into three; early, middle and late 
stages ofadolescence(Blum et al., 2017). 
Early Adolescence 
The period of early adolescence begins from age 10 to age 14. Physical development 
generally begins at this stage. Development is characterized by a growth spurt at the initial 
phase and then it is continued by the development of the sex organs and other secondary 
sexual features. It is early adolescence that girls and boys are more conscious of their gender 
than they were as children, and they begin making modifications to their lifestyles in order 
to adjust or meet up with the societal or perceived norms. In the process, the adolescent 
experiences either a burst of anxiety or pride at this stage of physical development (Curtis, 
2015; Taghizadeh Moghaddam, Bahreini. Ajilian Abbasi, Fazli, & Saeidi, 2016). The 
internal changes in the individual, although not as visible as the physical, equally 
overwhelms the adolescents (Lule & Rosen, 2009). According to UNICEF, 2011, the 
adolescent at this stage is vulnerable to taking risk, succumbing to peer pressure and being 
perplexed about their own individual and sexual identity(UNICEF, 2011). 
Middle Adolescence 
The middle adolescence is the second stage of adolescents' development. This spans from 
age 14 to 16. Adolescents at this stage are cautious of their looks. In addition, risk taking 
among them increases with the adolescence being extremely vulnerable to peer influences. 
Many of the adolescents' behavior and patterns of thought that develop during this period 
may extend into their adult life(Sawyer et al., 2018). The adolescent at this stage show more 
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signs of physical and psychological maturation. Hormonal changes most adolescents could 
cause feelings relating to sex, irritability, agitation. resentment and tension (Malin, Liauw, 
& Damon, 2017). 
Late Adolescence 
The age of 17 commences this phase of adolescents' development and ends at age 19. There 
are major physical advances at this stage with a lot of the physical features maturing. The 
adolescent's brain continues to develop, and they become analytical and reflective in 
thought. Vulnerability to peer opinions continues at this stage of development. However, it 
decreases as the adolescents gain increased understanding and boldness in their own identity 
and judgments (Curtis, 2015; Maliye & Garg, 2017) 
The concept of adolescent is dynamic and varies from one context to the other. In addition 
to the visible physical processes that the individual undergoes, other factors such as the 
psychological, social and cultural factors come to play in defining adolescence. The 
environment also plays a major role in the development process of the adolescent. Whereas 
an adolescent in a developed country will have access to their basic needs of life and 
intormation on their developmental needs, others in the less developed countries could have 
limited access (Taghizadeh Moghaddam et al., 2016). Lack of education, limited access to 
infonnation. culture and poverty predisposes adolescents, especially those in poor countries 
to risky behaviours. These behaviors include early marriages, trans-generational sex, and 
sex trading. 
In conclusion, programs targeting adolescents cannot be designed in isolation. The stage of 
the adolescents and the context all playa major role in programming for adolescents (Maliye 
& Garg, 2017). 
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As of2018, Cameroon had a total population of25, 914, 285 people and over 7million of 
these were youth and adolescents age 1O-24years(BUCREP, 2019). The HIV epidemic has 
not spared adolescents in Cameroon as there are over 40,000 living adolescents with HIV 
in Cameroon(UNICEF, 2015). Statistics from the World Health Organisation showed that, 
a total of 1200 adolescents died from HIV/AIDS related causes(WHO, 2017). This study 
will hence focus on HIV among Cameroon adolescents, with emphasis on unveiling the 
determinants related to their adherence and treatment outcomes. 
2.2 HIV and adolescence 
Adolescence (10-19 years) is a stage of physical growth and maturation that is characterised 
by sexual development and creation of intimate relationships (Naswa & Marfatia, 2010). 
mv positive children who live up to the adolescence, have challenges living up to their 
expectations as their normal lives are usually made complex by the presence of the HIV 
virus. (Vranda & Mothi, 2013). Hence. the adolescent mY/AIDS epidemic has its 
uniqueness and required to be managed cautiously and differently from the adults (ibid). 
This is so because adolescents who have the virus have to face the challenge of adhering to 
life-long medications and other adolescent issues especially those relating to their sexuality. 
HIV affects the lives of adolescents both socially, psychological, physically and health wise. 
Ont! characteristic that distinguishes HIV from other the other chronic illness is the stigma 
involved hence. adolescents and their families are faced with this stigma and the adolescent 
has to deal with it for a life time (Embree, 2005). In most cases, the adolescent and family 
live in a system of silence and shame which is linked with the disease (Vranda & Mothi, 
2013). This stigma could be from home, schools, hospitals and sometimes from the media. 
Stigma has been shown to determine an adolescent's ability to live positively with HIV as 
it is associated with shame, social isolation and depression (WHO, 2013a). 
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HIV positive adolescents are exposed to a number psychological factors over long periods 
oftime(WHO, 2013a). These could partly be attributed to status disclosure, thoughts about 
financial strains, adherence and other issues which can cause mental. A study by Gauhan 
and others in 2004 showed that HIV positive children and adolescents have a high burden 
of mental diseases (Gaughan et al., 2004). The mental issues are bound to happen as 
adolescents begin thinking of the future and how to live on. These thoughts could be 
worsened if they are not offered adequate psychosocial support and counselling. 
Health wise, adolescents with HIV are faced with the challenge of adhering to ARVs by 
taking medications on daily basis. They are also supposed to keep to hospital appointments 
which could sometimes affect their schooling and day to day activities. Furthermore, some 
of the ARV drugs could cause side effects which may be a reason for them to skip school in 
severe cases. Some studies have shown that HIV is one of the commonest cause of 
hospitalisations among adolescents. One of such is the prospective cohort study in 
Zimbabwe which showed that hospitalisations were higher among HIV positive adolescents 
(Ferrand et aI., 2010). Another study in Southern Africa had similar findings as adolescents 
were reported to contribute significantly to hospital admissions (Gray, 2010). 
Additionally, some HIV infected adolescents are supposed have to support and sick parent, 
take of their finances and that of siblings. This could be worse if the adolescent has lost one 
or both parents and does not have adequate parental support(Smith Fawzi et al., 2010). All 
these complicates the life of the adolescent especially coupled with the HIV condition they 
are already battling with. 
In summary, the adverse effects of HIV on the growth and maturation of adolescents could 
cause numerous difficulties for them as they sail through their teenage age (Vranda & 
Mothi, 2013). Hence, as HIV infected children become adolescents, they need adequate 
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support in other to manage the complex issues of the disease, their sexuality and 
development(WHO, 2013a). Adolescents with HIV will need supportive advice which will 
inform their decisions and choices in life about their health, HIV disclosure to family and 
friends and their sexuality (Vranda & Mothi, 2013). This is important as this will prevent 
high-risk behaviours among the adolescents and promote safe healthy sexual behaviours 
(ibid). 
2.3 The Concept of Adherence 
There are varied definitions of adherence. A number of authors consider adherence to mean 
an individual's ability to follow treatment as planned, take medications at prescribed times 
and frequencies, and follow restrictions regarding food and other medications (Taddeo, 
Egedy, & Frappier, 2008; Sabay, Reddy, & Dhayarkar, 2011b). From another perspective, 
it has been defined as the extent to which an individual's behaviour of taking medication, 
following a diet, adjusting habits and attending clinics coincides with medical or health 
advice (Touchette & Shapiro, 2008; Chakrabarti, 2014). Moreover, adherence also refers to 
the ability of the patient to act in accordance with the prescribed interval and required 
dosage of the treatment (Cramer et 01., 2008). Adherence has also been considered as the 
degree to which a person uses a medication following the required medical prescription, 
including timing, dosing, and consistency (Chaiyachati, et 01.,2014). From these definitions, 
the common theme across them is the fact that, the patient has to take medications as per 
the prescriber's advice. Regardless of the definition, the associated benefits of treatment 
adherence can only be obtained if the individual follows the treatment prescription 
meticulously (Osterberg & Blaschke, 2005). 
Generally, the concept of adherence is similar in both developed and developing countries. 
However, in some places, compliance might be used for adherence, but in places like the 
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UK, the tenn concordance to treatment is preferred (Home et al., 2005). Compliance is the 
degree in which the individual's behaviour ties with recommendations of the prescriber. As 
for concordance, it is defined as a mutual relationship between the individual and the 
prescriber, where issues relating to treatment are discussed and an agreement is reached as 
to the treatment of choice which is acceptable to both the patient and the prescriber (Kane 
&, Robinson, 2010). 
Similar to concordance, adherence also means the act of involvement and active 
participation in the plan of care for a patient. The meaning of the concept of adherence is 
broader compared to compliance which is the extent to which an individual is able to go 
according to instructions which in the long run signifies commitment, understanding and 
agreement to his or her plan of care (Kane &, Robinson, 2010). These includes readiness to 
continue a peculiar program of care which details appointment for meetings, counseling and 
tests. An adherence of 95% or more is described as near perfect adherence. According to 
Bangsberg, the newer HIV regimens are more forgiving hence an adherence rate lower than 
95% could still cause viral load suppression (Bangsberg & Deeks, 2002). However, this 
does not pennit patients to fall short of adhering properly to their medications. Hence efforts 
are on the rise to increase acceptor rates of ARVs among HIV populations from 
governments and other organizations. However, there is the need for more specific 
initiatives and patient-oriented strategies to ensure correct use and increased adherence to 
ARVs at all levels (Nsimba, 2010) 
Compliance, however, has been criticised and rarely used as it means sticking to 
medications without any considerations of the patient's social and personal issues (Lutfey 
&, Wishner, 1999). Persistence is also another related tenn and it is defined as the sustained 
adherence over time to the medication prescribed (Kane & Robinson, 20 I 0). Adherence has 
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been generally used as it goes beyond compliance since the patient has to agree with the 
recommendations from the prescriber. With adherence, the patient is actively involved or is 
even seen as a partner as far as decisions regarding their care is concerned. 
Adherence is a complex and diverse issue that can change with time and with factors varying 
among patients and changing with time also (Kane & Robinson, 2010; Roux el ai., 2011). 
However, in cases of chronic illness, adherence could change over time and hence the term 
persistence may perhaps be used. In any case, regardless of which word is preferred or used, 
the impact of treatment can only be obtained if patients take their medications accordingly 
(Osterberg & Blaschke, 2005). From the literature, however, adherence is most widely used 
than any of the related terms. It is to this effect that the term is preferred and indeed used in 
the context of this study. 
2.4 Adherence to ART 
The number of people living with HIV and receiving ART has risen by a third since 2013 
and this is thanks to global efforts in improving access to ARV drugs (Heestermans, 
Browne, Aitken, Vervoort, & Klipstein-Grobusch, 2016). By 2015, there were 17million 
people receiving ARVs globally and there are expectations of further increases as per the 
UNAIDs target (ibid). 
Treatment and management of chronic diseases and conditions entails a system of 
medication which is usually based on long period of continuity, with failures resulting into 
sup-optimal medication outcomes, re-hospitalization, increased cost of care as well as more 
time lost. The World Health Organization has documented non-adherence to medication and 
treatment regimen for chronic diseases and conditions highly problematic with non-
adherence rates varying from 15-39%, and 50% as an average (WHO, 2003). Various factors 
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determine adherence to treatment among diverse populations. The factors range from social 
to economic factors, health system related and individual-related factors (Kalogianni, 2011). 
HIV has remained a chronic disease affecting many people across the globe especially in 
countries of Sub-Saharan Africa. However, there has been significant improvement in 
treatment especially with the use antiretroviral treatment (ART). The introduction and use 
of ART has transformed the HIV disease to a chronic illness in which patients remain on 
treatment for a life time (Chaiyachati et ai., 2014). Certainly, the introduction and use of 
ART since the 1990s has significantly increased the survival of HIV infected persons 
especially in Africa. Although ARVs do not cure the virus, they control viral levels and can 
substantially reduce the viral load so that in some cases it becomes undetectable in blood 
samples as long as the patient can adhere to treatment (Laing & Hodgkin, 2006). 
According to the World Health Organisation, ARTs do not only prolong life but can also 
reduce HIV transmission to others (WHO, 20 13b). However, it requires the patient to adhere 
critically to medications because an increase in adherence is usually accompanied by a 
reduction in the viral load. A study by Cohen showed that, poor adherence to medication is 
a predisposing factor for the development of drug-resistant HIV strains (Cohen et al., 20 11). 
This was further confirmed by N garina and others that revealed that, low levels of adherence 
were associated with high viral loads and replication of drug resistant viruses which may 
require more complicated treatment regimen as well as increased cost of care (Ngarina M. 
Popenoe R, 2013). Furthermore, adherence to ARVs prevents the e of AIDS, other 
opportunistic infections as well as emergence of drug-resistant strains of the virus. Hence 
improvements of adherence is a one of the key strategies to reduce and possibly end 
HlV/AIDS. 
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In order to improve access to ARVs, the WHO launched the "3 by 5" initiative which was 
aimed at treating 3 million HIV positive persons by 2005 (WHO, 2004a). According to this 
initiative, WHO aimed at providing ART to 3 million people by 2005 in low and middle 
income countries however, only 43% of this target was achieved as only 1.3million people 
received ART by 2005 (Hardon e/ al., 2006). This initiative was closely followed at the end 
of 2005 by another target, which aimed at universal access to treatment by 2010 for all 
people with HIV (ibid). The commitment of universal access to treatment was done by the 
08 countries and was aimed at having all persons living with HIV on treatment by 2010 
(08,2005). 
The commitment towards universal access to treatment was, however, not achieved 
although some progress was made as more people were enrolled into treatment. Recently, 
the WHO declared the 90-90-90 target for HIV by 2020, with the aim to getting 90% of all 
people to be aware of their HIV status, 90% of all HIV -positive persons having access to 
treatment, and achieving 90% viral suppression for all on treatment(Levi et al., 2016). 
According to UNAIDS, some countries have made substantial progress towards achieving 
the 90-90-90 target. For example, Australia has achieved the first and second 90 target and 
is near achieving the third. Some African Countries like Botswana, Zambia, Zimbabwe and 
Algeria have achieved the second 90 while countries like Nigeria, Ethiopia and 
Mozambique are nearly achieving the second 90 (UNAIDS, 2017a). According to the 
progress made so far, Cameroon has not achieved and is not near achieving any of the 90-
90-90 targets. 
The use of ART has changed the HIV disease from being deadly into a chronically treatable 
condition for a greater proportion of people living with it; the worry with ART is how to 
maintain people on these medications given they have to take them for a life time (DHHS, 
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2016). Initially, this was partly because the drug regimens were complex, demanding and 
with multiple side effects and this caused a reduction in retention rates and adherence over 
time (Hansana el al., 2013). However, from 2016, there has been a lot of changes in 
regimens to friendlier and less toxic regimen, such as TenolamlEFV (TLE) and the recent 
shift to TenolamlDolutegavir (TLD) (Ibid}. 
Generally, adherence levels are lower in SSA compared to the developed world; it ranges 
from 60% to about 85% (Pefura-Yone, Soh, Kengne, Balkissou, & Kuaban, 2013; Letta, 
Demissie, Oljira. & Dessie, 2015). A study by Hawkins and others reported adherence 
levels in the UK to be 92% among adolescents(Hawkins el al., 2016). In Cameroon, 
adherence to ARV in adults was reported to be 73% after one month of ART initiation and 
this later dropped to 61 % 24 months later in 2011(Roux et al., 2011). These findings confirm 
the need for continuous assessment of adherence and its determinants as they change over 
time. Levels of adherence start declining in individual patients as they stay longer on 
treatment. Also, the need to maintain patients on treatment for a lifetime calls for the need 
for a long term perspective on adherence to ARVs. 
2.5 Consequences of Poor Adherence 
Adherence to the ARV drugs is necessary to obtain the whole benefit of treatment (Chesney, 
Morin, & Sherr, 2000). A major concern with ART is the development of viral resistance, 
which is has been attributed to poor adherence. Antiretroviral therapy reduces morbidity and 
mortality; however, these are dependent on the patient's ability to sustain adherence over 
time (Tiyou, Belachew, Alemseged, & Biadgilign, 2010). Evidence has shown that missing 
above 5-10% of doses is associated with increased CD4 counts, high viral loads, disease 
progression and in death in extreme (Machtinger & Bangsberg, 2006). It also increases the 
risk of viral transmission to others. 
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Moreover, poor adherence could cause a an increase in the replication rate of HI V with more 
susceptibility to mutations in the process, which has been associated with the development 
of new strains with reduced sensitivity to antiretroviral drugs (Walsh, Mandalia, & Gazzard, 
2002; Chaiyachati et al., 2014). It is thus necessary to pay attention to adherence to treatment 
because non-adherence adversely affects treatment outcomes and could cause more 
undesirable effects. This should therefore be an important component and priority of public 
health efforts in improving and sustaining ART adherence. 
2.6 Adolescents living with HIV 
Adolescents with mv can be classified into two groups: those that acquired the infection 
through mother-to-child-transmission also called vertical transmission (perinatally infected) 
and those that acquired horizontally, sexually or through blood transfusion (Denison, Koole, 
cl a/., 2015). An estimated 64% of all newly diagnosed HIV infections among adolescent in 
2014 (140,000 out of 220,000) were reported in adolescents of Sub Sahara Africa and 71% 
of new adolescent infections in this region (98,000) were among girls (UNICEF, 2015). 
There are a substantial number of HIV positive adolescents live many parts of Africa who 
do not know their HIV status and are not opportune to counselling and testing services and 
hence some of them continue to be a source of new infections without their knowledge 
(Adejumo, Malee, Ryscavage, Hunter, & Taiwo, 2014). Although most of the new 
infections that are diagnosed in children and adolescents daily are mainly attributed to 
mother to child transmission, there is a small proportion of infections that are transmitted 
sexually (WHO, 2013a). Both have mUltiple, complex, overlapping, and different 
challenges to adherence (Sung-Hee, McDonald, Kim, Foster, & Fidler, 2015). From Figure 
1, the incidence of global HIV infection among adolescents was very high around the year 
2000 and started declining. 
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500000 
450000 
400000 
350000 
300000 
250000 
200000 
Figure I: New HIV infections globally 2000-2016 among Adolescents (10-19 years) 
Source: (UNAIDS, 2019) 
The incidence was particularly high between 2000 and 2002 because children born to HIV + 
mothers from the late 80s had survived to adolescence. The significant drop from 2000 was 
probably because of the Prevention of Mother to Child Transmission (PMTCT) of HIV 
programmes which were introduced and scaled up and thus significantly reduced 
transmission to children. 
Even though enonnous efforts made by the global community championed by WHO and 
other partners to scale down HIV infection and to improve on HIV treatment which have all 
lead to substantial reductions in HIV morbidity and mortality, Africa especially South of the 
Sahara still lags behind in adequately responding to the public health problem. Figure 2 
shows HIV prevalence by country in Africa among adolescents. Although Cameroon is not 
one of the highest hit countries, the number is still very high: between 20,000 and 49,999 
adolescents were infected with HIV by 2014. In addition. over 50% of all the adolescents 
with HIV live in 20 countries, with South Africa taking the lead. These countries are known 
as the high burden countries and Cameroon is one of these as shown in Figure 3. 
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Figure 2, Global distribution of number of adolescents aged 10-19 years living with HI V 
by country in 2014 
Source: (UNICEF, 2015) 
TOTAL 2,000 
Bralt! 
31000 
1,\ 
'...fe-·;lCf"a!IC~Jt 
U,,,,,,,;,1IIg< 
36,000 
1'11. 
Umted RepublIc nf Tanzama 
110,000 
Figure 3, Proportion of adolescents aged 10 - 19 living with HIV, by selected high-burden 
countries 2014 
Source: (UNICEF, 2015) 
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2.7 Adherence to ARV among adolescents 
Generally, the goal of Anti-Retroviral therapy is to suppress the virus to the lowest level for 
a long time, preserve or restore the body's immune function, improve as well as prolong the 
life of the patient taking the treatment (Elaine Gross, 2004). 
According to the World Health Organization as cited in Nachega et aI., 2009, the number of 
adolescents on ART continues to be on the rise (Nachega et al., 2009). This reflects major 
improvements in antiretroviral therapy (ART) availability and access as well as a successful 
treatment ofperinatally infected children (ibid). It could also be due to newly acquired HIV 
infections through high-risk behaviour during early adolescence (Evans et al., 2013). In 
2016. ART coverage among children below IS years in sub-Saharan Africa was only 43% 
compared with 54% in adults (15 years and older) (Kasedde, Kapogiannis, McClure, & Luo, 
2014). As the number of adolescents on ART continue to increase, the challenge of 
obtaining and maintaining adherence over time for this age group has been difficult and 
pose a problem for survival and further disease spread (Hudelson & Cluver, 2015). 
According to the HPTN052 study, the paradigm shift in HIV prevention strategies to reduce 
HIV transmission and improve viral suppression must include risk groups like adolescents 
and adults living with HIV otherwise the global agenda will not be achieved(Cohen et aI., 
20 II). Therefore, the subject adherence among adolescents is of utmost importance as they 
are also part of the global 90-90-90 UNAIDS target for HIV by 2020. 
Adolescents are at risk of suboptimal adherence and have challenges in suppressing viral 
replication, and this increases the chances of viral progression and the occurrence of 
opportunistic infection, transmission to sexual partners and viral resistance (Hudelson & 
Cluver, 2015). Moreover, fmdings from a study by Adjumo and others are of the view that 
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horizontally-infected adolescents are more at risk of poor adherence compared to their 
perinatally infected peers (Adejumo el al., 2014). 
Sub-Sahara Africa has 85% of all the adolescents with HIV (Kasedde, Luo, McClure, & 
Chandan, 2013). About 1.3 million of the adolescents with HIV in Sub-Saharan Africa are 
in Eastern and Southern Africa, with an estimated 390,000 of them living in West and 
Central Africa (Idele et al., 2014). With this significant proportion of ALHIV, it is necessary 
to discuss their adherence. However, few studies have measured adherence among 
adolescents around Africa, although adherence has been reported to be lower than that of 
other age categories (ldele et al., 2014; Maskew et al., 2016). Adherence among adolescents 
in Africa has been reported by Kim et aI., 2014 to be 62.3%. This result was obtained from 
a meta-analysis. The results suggested that adolescents in Africa were adhering more 
compared to those in areas like North America where adherence is as low as 54% (Sung-
Hee et ai., 2014). Despite this higher adherence among African adolescents, there is still a 
need to improve on it given that Africa has more of the ALHIV. 
By the end of 2015, an estimated 7,100 children and adolescents less than 15years were 
recruited to treatment, although the proportion was expected to increase due to the universal 
access to ART for children program that was initiated nationwide (Fokam et al., 2017). A 
study in Yaounde, Cameroon, reported adherence to be 36% in 2017 among adolescents 
(Fokam et ai., 2017). Despite the significant number of adolescents already enrolled into 
treatment, little research has been done on the determinants of adherence in Cameroonian 
adolescents. With this huge number and the expected increase in the prevalence of HIV, 
there is the need to ensure adolescents are retained in treatment so as to achieve optimum 
adherence and hence clinical success. 
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2.8 Treatment Outcomes 
Prior to ART and even in untreated cases today, HIV infection leads to gradual deterioration 
of the immune system (that is, AIDS), which could cause morbidity and even mortality 
(Enriquez and McKinsey, 2011). However, the use of antiretroviral (ARV) treatment has 
changed the disease to a life time infection which can be managed if the treatment is taken 
properly (Bor et al., 2017). Generally, adherence to ART improves treatment outcomes. 
Studies have shown for example that, majority of the patients adhering to treatment are 
retained in care (Babatunde et al., 2015). The treatment outcomes range from viral load 
suppression, retention in care, CD4 counts, mortality and morbidity. 
2.8.1 Viral load suppression 
Several studies have shown that the goal of HIV treatment success is suppression of HIV 
viral load (Enriquez and McKinsey, 2011). This entails that HIV -infected patient should 
have full access to treatment and take daily for a lifetime (DHHS, 2016). The reduction of 
the HIV RNA to below 400copies/ml of blood is termed viral load suppression (Geretti e/ 
al., 2008). Two successive viral loads conducted with results above 1000copies/ml indicates 
that treatment has not been successful (WHO, 2016a). However, reduction in viral load does 
not necessarily imply the person is cured but indicates that the virus has been controlled. 
The major objective of antiretroviral therapy is to reduce replication of the virus to an 
acceptable level. This is because viral load suppression catalyses restoration of the immune 
system and substantially reduces the chances of disease spread (Chhim et al., 2018). 
Furthermore, a reduction in viral load is also essential for reducing morbidity and 
mortality(UNAIDS, 2017a). Consequently, the World Health Organization (WHO) in 2013 
introduced viral load suppression monitoring as a gold standard to follow up the treatment 
success (WHO, 2013a). Given the importance attributed to viral load suppression, UNAIDS 
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made viral load suppression as one of the targets to achieve by 2020 among HIV patients 
wherein, 90% of all HIV positive patients are expected to have suppressed their viral loads. 
The Centre for Disease Control(CDC) released a report in 2014 showing that only 57.9% of 
all HIV positive persons had suppressed viralloads(CDC, 2014). According to UNAIDS 
data for 2016, viral load suppression among HIV positive persons was 19%(UNAIDS, 
2016a). However, a recent study in Cameroon reported a viral suppression of 72% among 
patients who had been on treatment between 12-24months and 67% among those who have 
been on treatment for at least 48months (Tchouwa et al., 2018). Although these results show 
an improvement from the report of UNAIDS in 2016, it still fall shorts of the global 
expectation of 90% for viral load suppression. 
Generally, viral load suppression for adolescents should be comparable to adults initiating 
similar regimens. However, some cohort studies have shown otherwise with suppression 
lower in adolescents compared to adults, with rates from 28% to 78% compared to 90% for 
adults on similar regimens (Agwu & Fairlie, 2013). Normally, with appropriate adherence 
to therapy, viral load suppression is expected to occur in 6 months of ART initiation. The 
use of viral load measurements is also important as it offers the opportunity to monitor 
progress towards the third 90 of the UNAIDS 90-90-90 target, with an ambitious target of 
having 90% of all the receiving antiretroviral therapy suppress their viral loads by 2020. 
In Cameroon adolescents have been reported a lower viral load surpression compared to 
adults. A longitudinal cohort study by Fokam and others in Yaounde reported a suppression 
of 52% among vertically infected adolescents (Fokam et al., 2017). This is lower than the 
suppression of reported in adults of 72% reported among adults in Cameroon(Tchouwa et 
al., 2018). The study by Fokam among adolescents is one of the few in Cameroon that has 
reported viral load surpression among adolescents and this was done in Yaounde (Centre 
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Region). The present study is therefore adding to this but assessing this treatment outcome 
in another part of Cameroon-North West and South Regions. 
2.8.2 Lost to follow up (L TFU) 
Lost to follow up (L TFU) is defined as patient missing clinic days and refill for more than 
90 days since the last clinic visit and has not been registered as a transfer case or death (Chi 
et a/., 2011). Although there have been significant improvements in ARV treatment, there 
are still cases of treatment dropout along the treatment (Berheto, Haile, & Mohammed, 
2014). Lost to follow up has been shown to accounts for almost 56% of all attrition 
(Babatunde et al., 2015). Studies carried out in some parts of Sub-Saharan Africa have 
shown that about SOOAl of the people who test HIV -positive are lost and 32% of the people 
considered eligible for ART are sometimes do not end of making themselves available for 
treatment (Wools-Kaloustian et al., 2006). 
Findings from a study by Bertho and others 2014 indicated that the mean retention for people 
on ARVs reduces with time, from an estimated 86% at 12 months to 72% by five years 
(Berheto et a/.. 2014). Some studies from Sub-Saharan African countries have estimated 
that about 20% to 40% of patients on ART are lost to follow-up (ibid). Loss to follow-up 
(LTFU) causes non-adherence which could lead to an increase in morbidity, 
hospitalizations and sometimes mortality (Taiwo, 2009). Some predictors of lost to follow 
up are; decreased CD4 counts, occurrence of opportunistic infections such as tuberculosis, 
unreliable services, drug side effects. younger age like the case of adolescents and advanced 
stage of disease (Wools-Kaloustian et al., 2006). The chances of attrition are always seen to 
increase as patients stay longer in treatment (Berheto et al., 2014). 
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2.8.3 Retention 
Retention in HIV care can be defined as the continuous engagement to a full package of 
care aimed at preventing, treating and supporting the patients immediately they are initiated 
into treatment (Babatunde et al., 2015). It also includes the patient's ability to stick to 
important aspects of the treatment, perform requested laboratory exams and follow-up clinic 
appointments as per the national standards or based on the advice of the practitioner (Patel, 
Hirschhorn, Fullem, Ojikutu, & Oser, 2010). Retention can be defined at 3months, 6months, 
12months. 24months and even 36months. 
Globally, retention rates stand at 94% and 83% at 6 and 12 months respectively (Fox & 
Rosen, 2017). In Sub-Sahara Africa, retention rates have been reported to range from 50 to 
70% at 2years (Babatunde et aI., 2015). For paediatric HIV patients in low and middle 
income countries, retention has been reported to be 88% at 12 months, 72% at 24months 
and 67% at 36 months (Fox & Rosen, 2015). Retention in care decreases HIV related deaths 
and morbidities, as well as the incidence of new infections and emergence of HI V resistant 
strains (WHO, 2012). Some factors that reduce retention include advanced illness, stigma, 
unregistered transfer outs, provision of inaccurate personal information by patients and 
financial issues (ibid). Retention in care can be improved by offering ART care immediately 
(Bor et af., 2017). 
2.8.4 CD4 Counts 
CD4 counts measures the number of CD4 cells in the body. CD4 cells are a class of white 
blood cells known as T-cells. They are used to monitor immune response to infection. The 
normal CD4 count ranges from 500 to 1000 cells. When the CD4 count drops to below 200, 
it is considered as the advanced stage of the disease otherwise known as AIDS (Wood et al., 
2003). Evidence has shown that ARVs improve CD4 cell counts, which in leads to decreases 
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morbidity and mortality in HIV-infected persons (Wood et aJ.. 2003). Generally. as viral 
load increases. CD4 count decreases; therefore a low CD4 count is a consequence of 
virologic failure (Bisson el al., 2008). Hence, the higher the CD4 count, the better for the 
patient on treatment and this suggests that CD4 counts could be al so be a way of monitoring 
patient's response and compliance to treatment. 
2.8.5 Mortality 
Mortality refers to deaths, and in this case, HIV related deaths. A review by kasedde and 
others in 2014 showed that, there \\as a decrease in HIV-related between 2005 and 2012 by 
30% in other age groups. However. deaths among adolescents was rather seen to increase 
during this time by 50% (Figure 4) (Kasedde et al., 2014). 
T_oU.I  adolescent AIDS-related deaths Total AIDS-related deaths 
-2!iOO-ooo- ----------
~~=~~ 1_000 
-300-00- -----_._------
21. 
!iOOooo 
lIa 
,0 ___0_  __  
2001 2lI02 2003 2004 2OD!> 2006 2007 20GII ..... 211\1 21111 2001 2002 2003 2004 2005 200II 2007 2008 2008 2010 2011 
I igure 4: Total AIDS related deaths and deaths in adolescents 
Source: (Kasedde et al., 2014) 
HIV currently ranks as the second leading cause of adolescent deaths globally but ranks first 
among African adolescent girIs(UNAIDS. 2016c). In young adolescent boys, HIV is the 
third leading cause of death as of 2016(ibid). The observed rise in adolescents mortality 
from HIV w as attn' bu te d to lack of appropn.a te adolescent services to take care of the 
specific needs of the adolescents ranging from treatment to support services that could 
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enable adolescents adhere to medication and hence improve their treatment 
outcomes(WHO. 2013a; Lall et al., 2015). 
Quality life among HIV positive adolescents 
The initiation and use of Anti-retroviral therapy (ART) in HIV management has seen a 
reduction in morbidity and mortality among people living with HIV. Furthermore, ARVS 
also increase life expectancy and quality oflife for most people living with HIV at the same 
time reducing the HIV transmission risk (Garcia de Olalla et al., 2002; Sethi, 2003; Samji, 
2013; Bukenya, 2019). Furthermore, early treatment has increased the life expectancy of 
HIV patients to near normal. The primary goals of antiretroviral therapies (ARTs) are to 
control HIV replication, restore and preserve the immune system, decrease HIV 
transmission and infections, reduce complications caused by HIV and improve quality of 
life and survival (Garcia de Olalla et aI., 2002). 
The World Health Organization has defined Quality oflife as an individuals' view of their 
state in life within the context of the culture and value systems in which they live and relate 
to their goals, standards, expectations and worries(WHO, 1998). The patient's quality oflife 
also impacts the capacity to adhere to ARV treatments as well as treatment 
outcomes(Cooper, Clatworthy, Harding, & Whetham, 2017). Quality of life is measured 
using the WHO quality of life score tool which contains six domains namely; physical, 
psychological, level of independence, social relationships, environment and spirituality 
(WHO 1998) in (Dewan, GK, & Jiloha, 2009). 
Given the developmental stage of adolescents, measuring quality of life among them is 
imperative because it provides a more detailed monitoring of the physical, mental and social 
well-being of children and adolescents within their own stage (Lea, Gortmaker, McIntosh, 
Hughes, & Oieske, 2006). With increase access and availability of ARV drugs, the quality 
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of life of HIV positive adolescents has increased (Aurpibul, Oberdorfer, Choeyprasert, & 
Louthrenoo, 2016). This study further affirms that the increased availability of ARVS has 
given a chance to children who were infected with HIV from mother to child to live to 
adolescents (Aurpibul et al., 2016). 
In Cameroon, a few studies have assed depression, and other psychological factors that can 
impact adherence (Gaynes et al., 2012; Fonsah et al., 2017). The quality of life of HIV 
patients which is also key to their adherence as well as treatment outcomes has not been 
studied in Cameroon. 
2.9 Adolescents' perspectives on DIV and ART adherence 
Adolescents are gradually gaining prominence in the response to HIV as seen in the efforts 
of UNA IDS and other partners launching projects targeting adolescents (Armstrong, Rachel, 
Jane, Anke, & Liezel, 2013). Evidence also show that the number ofHIV related deaths are 
reducing in other age groups but, however increasing in adolescents(UNICEF, 2015). Given 
the situation, it is imperative to understand their perspective on HIV and ART adherence. 
According to the UNAIDS guidelines, it is necessary to partner with adolescents, understand 
their perspective and hence offer HIV care to them that is adequate and acceptable 
(UNAIDS,2016b). 
Perception is about an individual's beliefs that they can exert control over their own 
motivations, thought processes, emotional states and behaviour patterns (Wasti, Simkhada, 
Randall, Freeman, & Van Teijlingen, 2012). When these perceptions especially in the case 
of ARVs are negative, adherence is poor. Adolescents, like adults, vary in their opinion 
about adherence. While others deny the existence of the disease or perceived side effects, 
some believe that feeling better could mean the disease has been cured (Dahab et al., 2008). 
Adolescents also find health workers, peers and partners as significant others who can help 
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improve on adherence and often feel that judgmental attitudes from health care providers 
negatively influences adherence (Armstrong et 01.,2013). 
In addition, inadequate social support for taking medications, break from medications, 
failing to understand the importance of drugs, beliefs of being able to stay healthy without 
HIV medications are some perceived factors reported to be related with poor medication 
adherence (MacDonell et 01.,2013). Health care providers also have their own views on 
ARV and they believe that long waiting time, work pressure on them, language barriers and 
insufficient time spent with adolescents are some barriers to adherence (Weiser et 01.,2003). 
The challenges of adherence are discussed below. However, a the believe in the value of 
treatment also helps adolescents to adhere to treatment (Dahab et 01., 2008). In addition, 
adolescents also believe that if other HIV positive adolescents who are adherent to treatment 
are used as models to share life experiences on how they live with the virus, it could help 
boast adherence among them (Armstrong et ai., 2013). 
2.10 Challenges to Adherence 
The use of ARV medications has significantly scaled down morbidity and mortality from 
HIV globally(CDC, 2014). However, the ability of treatment to increase the quality of life 
depends on the extent of adherence. A number of studies have shown some of the factors 
that could hinder the patient's ability to adhere to medications as per prescription (Wools-
Kaloustian et 01.,2006; Jayaweera et 01.,2009). As previously discussed, adolescents with 
HIV have been found to have lower retention in care compared with adults on a global scale 
and this can be attributed to a number of individual, social and health system related issues 
(Willis et a/., 2019). In spite ofthe global effort made to improve adherence in adolescents, 
ALHIV, their guardians or parents are still unable to access adolescent-specialised services 
which can enable them manage the disease (Denison, Banda, et 01., 2015). 
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Among adolescents, the simple thought process makes it challenging for them to understand 
and accept the need to take lifelong medications especially when they have no symptoms 
and not sick (Elaine Gross, 2004). This is the case when the treatment is taken every day 
like in the case of ARVs. Adhering to ARV treatment comes with challenges which vary 
among adolescents. Enriquez & McKinsey, in their review, identifies a number of barriers 
or challenges as well as facilitators of ARV therapy adherence (Enriquez & McKinsey, 
2011). These barriers to HIV treatment adherence as identified by the authors can be group 
under several major categories and include individual, socio-economic factors, health 
service factors and medication related issues. 
2.10.1 Individual factors 
Adolescents who are HIV positive go to school, work, play or carryout routine domestic 
activities just like their counterparts who may be free of the virus. These activities may thus 
hinder adherence and as a result, many adolescents are discouraged from taking medications 
because they do not want others to learn about their HIV status especially due to the stigma 
attached to HIV (Murphy et al., 2003). Recently diagnosed adolescents have difficulties 
accepting the situation, and some could resort to drug use and alcoholism, which also 
impede adherence to ARV s (Shubber et al., 2016). For some adolescents, being out of home, 
fear of stigma, using of traditional medicines and denial of status, that is refusal of the HIV 
positive status are some of the individual barriers adolescents face while taking ARVs 
(Dahab et al., 2008). Likewise, psychosocial factors, such as despair, guilt and safe have 
been seen to hinder adherence (Lall et al., 2015). 
2.10.2 Medication Factors 
Adolescents face medication related side effects like insomnia, hallucinations, 
lipodystrophy (redistribution of body fat), rashes or discoloration of the skin, that change 
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their physical appearance and act as barriers to adherence (Merten et al., 2010; Sung-Hee et 
al., 2015). Pill burden. severity of HI V as a disease and low perceived need for medication 
are some challenges of medication adherence in young people (Buchanan et al., 2012). In 
addition, medication frequency, taste and treatment fatigue are also some factors that make 
adherence to ARV difficult (Sung-Hee et al., 2015). Feeling well after taking medication is 
also another reported barrier since there is the temptation to stop medication (Dahab et al., 
2008). 
2.10.3 Hcalth Service factors 
Health service factors are factors related to provision of care and availability of adolescent 
friendly services. These factors include long waiting time for drugs, laboratory tests and 
other clinic services, which take long and hence discourage adolescents from keeping to 
their appointments (Dahab et al., 2008). Long distance to clinic, poor quality of care, 
transportation costs and inconvenient clinic hours for adolescents are some of the barriers 
adolescents face as they take ARVs (Hudelson & Cluver, 2015). Also, poor communication 
and little or no trust in health care providers also impede adherence as there is no forum for 
discussion especially when adolescents encounter difficulties with their medications (Dahab 
el al., 2008). Impaired access to healthcare services together with smaller services and small 
staff numbers have been shown to also impede adherence (DagH-Hernandez, Lucchetta, de 
Nadai, Galdur6z, & de Carvalho Mastroianni, 2016) 
2.1 0.4 Socio-economic Factors 
Infected adolescents face a number of life stressors which range from poverty, unstable 
family, movements or transfers to new environments. These factors which can also impede 
their access to ARVS and hence and adherence (Havens, Mellins, & Hunter, 2002). In the 
case of poverty, they might need to pay clinic fees, transport and other hospital expenses. 
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Sometimes proper feeding and schooling becomes difficult in cases of poverty and this 
makes adherence quite challenging (Abanem & Bongfen, 2017). 
2.11 Determinants of Adherence to Anti-Retroviral Therapy among adolescents 
The determinants of adherence are those factors that undermines/supports an individual's 
ability to adhere to treatment. The maximum benefits of ARV s  which are desirable treatment 
outcomes can only be obtained when patients adhere to treatment(Lyimo et al., 2012). The 
task of adhering to medication is not easy and has been seen to be affected by a number of 
determinants. They are many and range from socio-demographic, socio-cultural and patient 
to health service factors as discussed below. 
2.11.1 Socio-demographic Factors 
Socio-demographic factors can determine patient's adherence. Some of the demographic 
factors include age, sex, literacy level, place of residence, religion, distance to health facility 
living and with parent/guardian 
2.11.1.1 Age 
The relationship between age and adherence is complex. While some studies show age to 
significantly influence adherence others show otherwise. One systematic review for 
example revealed a positive relationship between age and adherence: younger age was 
shown to be associated with good adherence (Hudelson & Cluver, 2015). Findings from 
South Africa in a qualitative study also reported younger age to significantly influence 
adherence while older age was a barrier (Dahab et al., 2008). However, a study carried out 
by Dagli-Hemandez et a1. (2016) found age not to have any significant relationship with 
adherence. In addition, findings from Uganda in a mixed method study showed age to have 
no significant association with adherence (Nabukeera-Barungi et al., 2015). A survey in 
Kenya also reported age group 15-24 to be associated with poor adherence (Mukui et al., 
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2016). Further, results from a mixed method study in Tanzania revealed that age had no 
relationship with adherence (Nyogea el al., 2015). Given the complexity of age and 
adherence as reported in previous studies. the present study will therefore asses the nature 
of the relationship in the Cameroon context. 
2.11.1.2 Sex 
A review of literature showed the relationship between sex and adherence to be inconclusive 
just like in the case of age. According to Nyogea et al., 2015 in a mixed method study, sex 
does not have any significant relationship with adherence. Also, findings from (Mukui et 
aI., 2016) showed sex to have no association with adherence. A Ugandan study by 
Nabukeera et aI. (2015) as well as a study by Dagli-Hemandez et al. (2016) showed similar 
findings with sex having no relationship with adherence. However, being male was 
significantly related with adherence in a study among Ugandan adolescents as males 
reportedly had higher adherence compared to female (Wiens et al., 2012). However, the 
same male gender was significantly associated with poor adherence in a study in Botswana 
(Ndiaye el al., 2013). Given these differences in relationship between sex and adherence, 
this study will also evaluate this relationship. 
2.11.1.3 Educational level 
Literacy level of adolescents has also been shown in literature to determine adherence; the 
nature of the relationship is however complex as the relationship is often bi-direction. A 
study by Hubrich and others in Brazil showed no significant association between 
educational level and adherence (Haubrich et al., I 999). Further studies by Nyogea et al. 
(2015) and Hudelson et al. (2015) showed similar findings with no significant relationship 
with adherence. However, studies by Dahab (2008), Zao (2009), Mukui and others (2016) 
showed that a higher level of education is significant predictor of good adherence (Dahab 
et aI., 2008; Zou et al., 2009; Mukui et al., 2016). Nevertheless, a study in Nigeria found 
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higher level ofeducation to be significantly related with non-adherence (Uzochukwu el al., 
2009). 
2.11.1.4 Distance to Health Facility 
The other demographic variables like distance to health facility have also been shown to 
affect adherence in some studies. A study in rural Zambia showed that despite long distance 
to health facility, patients were still very adherent (Carlucci el al., 2008). However, another 
study in Zambia in 2012 showed long distance to health facility to be associated with non-
adherence(Yuri el al., 2012). A study in Zimbabwe also revealed that patients who have to 
travel longer distances of over 10km from home to health facilities were having sub-optimal 
adherence compared to those who were closer to the health facilities (Gonah & 
Mukwirimba. 2016). Furthermore, results from a study in Nepal found that long distance to 
health facility was significantly associated with non-adherence (Wasti ef aI., 2012). 
2.11.1.5 Religion 
Religion is another demographic variable that can affect adherence and its impact on 
adherence has been shown in a few studies. A study in Uganda showed that belonging to 
certain religions was associated higher adherence. According to the findings of this study, 
Christians of the Pentecostal denomination as well as Muslims had a higher adherence 
compared to the others (Kisenyi, Muliira, & Ayebare, 2013). Conversely, a study by 
Wambugu and others in Kenya showed that religious affiliations did not have any 
association with adherence to ARVs (Wambugu, Peter, Mbuthia, Joshua, & Ndwiga, 2018). 
2.11.2 Socio-cultural factors 
The most common reported socio-cultural barriers to medication in both low and high 
Income countries include; use of traditional medicines, beliefs in spiritual healing, fear of 
disclosure, inadequate social support, interpersonal violence and alcohol use (Merten el al., 
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2010). Alcohol use especially during festive periods, stigma and lack of family have 
particularly been sho'wn to hinder adherence in HIV positive patients in Nepal in a mixed 
method study (Wasti et a/., 2012). 
2.11.2.1 Use of traditional medicines 
Traditional medicines which in some cases are referred to as complementary and alternative 
medicine generally include herbs, spiritual beliefs, acupuncture, acupressure, chiropractic 
care, massage therapy, meditation, visualization, therapeutic touch and micronutrients such 
as vitamins, minerals and multivitamins (Heestermans et af., 2016). Some studies have 
shown that traditional and complementary medicines is widely used by HIV patients (Babb 
el al., 2007). Although in great use, the effect of these medicines on medication adherence 
to treatment has been similar across studies. For example, a study in South Africa reported 
that, the use of herbal remedies among HIV positive patients was causing their adherence 
to ARV to decrease over time (Peltzer et al., 2011). Furthermore, results of Peltzer's study 
in South Africa showed that the use of herbal medicines was associated with non-adherence. 
A study in Ethopia by Legesse also had similar findings as the use of traditional medicines 
had a significant association with adherence (Legesse & Shewamene, 2015). Additionally, 
Dahab showed that an individual's belief and preference for other traditional systems of 
medicines also negatively affect adherence as they sometimes prefer these traditional 
medicines to ARVs (Dahab et al., 2008). 
2.11.2.2 Beliefs in Spiritual Healing 
Beliefs in spiritual healing is another socio-cultural determinant of adherence. Given the 
complexity surrounding spiritual issues, its relationship with adherence to ARV  has not been 
given a lot of attention, however, few studies have reported on its effect on ARV adherence 
among people with HIV. A study by Thielman in Tanzania showed that beliefs in spiritual 
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healing was linked with lower adherence(Thielman et al., 2014). However, findings from a 
study by Zou et al showed that adherence to ARV was not significantly associated with the 
belief that prayer could cure HIV or with other religious factors (Zou et aI., 2009). These 
results were similar to those of another in Zimbabwe where religious beliefs had no effect 
on adherence (Gonah & Mukwirimba, 2016). 
2.11.3 Health Sen'ices and System Factors 
Health service factors that may predict adherence in adolescents include waiting time, clinic 
hours, doctor-patient relationship and service delivery. For the purpose of this study, the 
health system factors considered are waiting time and attitude of health service staff. While 
some studies report these factors to have negative impact on adherence, others say 
otherwise. Long waiting for instance was long waiting time showed no significant 
association with adherence in a study in Zimbabwe by Gonah and his team (Gonah & 
Mukwirimba, 2016). 
For the attitude of health service staff, findings from Mozambique indicate that poor attitude 
of staff could cause poor adherence (Marega, Pires, & Samuel, 2017). Whereas, a study by 
Kalichman et aI., 1999 showed that attitudes ofheaIthcare providers had no relationship with 
adherence (Kalichman, Ramachandran, & Catz, 1999).Similarly, poor staff competences 
and concerns about confidentiality are linked with non or poor adherence (Sanjobo, Frich, 
& Fretheim, 2008). 
2.11.4 Patient factors 
Adherence to ARV  can also be influenced by patient factors. These factors among others 
include side effects, internalized stigma, losing pills, being busy, other illnesses or comorbid 
conditions, waking up early and not understanding treatment regimen. 
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2.11.4.1 Medication related side effects 
Like most drugs, AR Vs  also come with related side effects. Some of these side effects 
decline over time although in some cases might cause a change in medications taken 
(Hardon et 01., 2006). The World Health Organisation defines drug side effect as a "a 
response which is toxic and unintended and which could occur at doses normally used in 
humans for the prophylaxis, diagnosis, treatment of disease or for the modification of 
physiological function (WHO, 2013b). Some of the common experienced side effects are 
nausea, headache, vomiting, anaemia and gastrointestinal tolerance (Negesa, Demeke, & 
Mekonnin,2017). Medication related side effects could also be visible for example, body 
changes, excessive perspitation, skin darkening, loss of hair, skin swelling gaining weight 
and rashes on skin (Li et 01., 2017). These visible side effects can cause low self-esteem, 
stigmatisation and hence lead to poor adherence to medication(Abel & Painter, 2003). These 
authors further noted that, in cases where the side effects persist, the patient might even quit 
taking medications for some time or completely. 
ARV drugs can also cause neuropsychiatric adverse reactions, examples include delusions, 
intense body heat, anxiety, dizziness and nightmares (Castro, Gonzalez, & Perez, 2015). All 
these side effect affect patient's ability to take medications. Some studies have shown that 
adverse drug reactions have an effect on adherence; a study in Malawi by Mckinney showed 
that adverse drugs reactions affected adherence (McKinney, Modeste, Lee, Gleason, & 
Maynard-Tucker, 2014). Similar findings were also reported by a study in China where side 
effects with the mediating role self-efficacy was shown to affect adherence(McKinney et 
aI., 2014). The present study will hence asses the relationship between adherence to ARVs 
and medication related side effects in the study area. 
Some of the HIV medications and their possible related side effects are as follows; 
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Nucleotide Reverse transcriptase Inhibitors (NRTIs): These drugs function to stop 
reverse transcriptase, which is an enzyme that HIV virus requires to make copies of itself. 
Examples of NRTIs molecules are Abacavir, Didanosine, Emitricitabine, Lamivudine, 
Stavudine, Tenofovir and Zidovudine (Esser, Helbig, Hillen, Dissemond, & Grabbe, 2007). 
The related side effects of the drugs are as follows; 
- Abacavir, the relate side effect is hypersensitivity reaction. 
-Didanosine is noted to cause diarrhoea, abdominal discomfort, neuropathy, nausea, 
vomiting and pancreatitis. 
- Emitricitabine can cause rashes on skin and darkening, numbness and tickling sensations 
-As for Lamivudine, can cause the patient nausea, vomiting, stomach discomfort, diarrhoea, 
fatigue, body weakness, headaches and sleeplessness in some cases 
-Stavudine could cause the patient to develop peripheral neuropathy, headache, chills, fever, 
diarrhoea, nausea, losing of body fat around the face and sometimes on arm 
-Tenofovir can cause undesirable effects such as vomiting, appetite loss, stomach upset and 
mild nausea 
- Zidovudine related side effects are anaemia, nausea and vomiting (Esser et al., 2007) 
Non-Nucleotide Reverse transcriptase Inhibitors (NNRTIs): These are drug molecules 
that work by binding to and later altering reverse transcriptase which is an enzyme HIV 
needs to make copies of itself (Esser et al., 2007). These drugs also have associated side 
effects as follows 
- Efavirenz which causes vivid dreams, anxiety, rash, nausea and sometimes insomnia 
-Nevirapine which is known for kin rash, fever, headache, nausea and also diarrhoea 
- Rilpivirine that causes depression, difficulty sleeping, headache as well as rashes (Esser et 
al., 2007) 
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Protease Inhibitors (PIs): Protease Inhibitors function by blocking protease, which is an 
enzyme used by the HIV virus to make copies of itself (Flexner, 1998). Examples of Pis are 
-Atazanavir: it causes side effects such as increased levels of bilirubin in blood, nausea, 
headache, skin rash, stomach upset, vomiting, diarrhoea and even changes in heart beat 
-Fosamprenavir which is associated with nausea. diarrhoea, vomiting, skin rash, numbness 
aroWld mouth and abdominal upset 
-Lopinavir can cause diarrhoea, fatigue, headache, nausea, weakness, rash and insomnia 
-Nelfinavir could cause diarrhoea, nausea, abdominal pain, weakness, rash, anaemia and 
joint pains in some cases 
-Ritonavir causes side effects such as nausea, vomiting, diarrhoea, changes in taste, 
headache. body weakness and skin rash 
-Tipranavir causes an increase in liver enzymes and cholesterol levels. It can also cause 
diarrhoea. rash, nausea, vomiting, stomach pain, fatigue and headache 
-Durunavir could cause some side which range from diarrhoea, nausea, headache and skin 
rash(Flexner. 1998). 
Fusion Inhibitors (FIs): These are the drug types that act by preventing the virus from 
binding to the cellular membrane of the host cell and hence blocking the entry of the virus 
(Trevor. 2006). The common fusion inhibitors is Enfuvirtide which can cause multiple side 
effects such as body itches, sleeplessness, depression, diarrhoea, mild nausea, body 
weakness, muscle pain, loss of appetite, weight loss and flu-like symptoms(ibid) 
Entry Inhibitors: These class of drugs inhibit the virus before it gets into the host cell. 
fheir mode of action is different from the fusion inhibitors (Qian, Morris-Natschke, & Lee, 
2009) . The common example is Maraviroc which possesses the following possible side 
effects; cough, stomach pain, tiredness and dizziness especially when standing (Qian el af., 
2009). 
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Integrase inhibitors: Integrase inhibitors prevents the HIV virus from making copies of 
itself by blocking a key protein that allows the virus to insert its DNA into a healthy cell 
(Lataillade & Kozal, 2006). Examples of integrase inhibitors are; 
-Dolutegravir causes side effects such as headache and insomnia 
_ Elvitegravir could possibly cause diarrhoea, nausea and headache 
_ Raltegravir causes headache, nausea, dizziness, tiredness and insomnia (Lataillade & 
Kozal,2006). 
2.11.4.2 Internalized stigma 
Internalised stigma in HIV care is a self- stigma in which an individual expresses negative 
thoughts or feelings about their HIV status(CDC, 20 IS). It is also known as imagined or feIt 
or perceived stigma (UNAIDS, 2006). Usually, the individual feels because they are 
ashamed, guilty or feel worthless about a particular health condition (Kalichrnan et aI., 
2009). It is different from the normal stigma which is from comes from other sources. 
HIV/AIDS-related internalised stigmas can cause declines in physical and mental health 
(Rael & Hampanda, 2016). Internalised stigma is usually measured using six questions 
developed by kalichman. These are; 
-It is challenging to tell people about my HIV positive status 
- My HIV positive status makes me feel dirty 
-I feel guilty because I am HIV positive 
-My HIV positive status makes me ashamed 
- I sometimes feel worthless because I am HIV positive 
-I hide my HIV positive status from others. 
According to CDC 2018, a patient who answers yes to any of the above questions is 
considered to be experiencing internalised stigma. In the United states, SO% of HIV patients 
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reported experiencing internalised stigma(CDC, 2018). This form of stigma was shown by 
Simbayi et af to affect adherence among HIV patients (Simbayi et al., 2007). Findings from 
Whitnney and others also showed similar results as internalised stigma was negatively 
associated to adherence (Rice et al., 2017). Another study revealed that, internalised stigma 
caused depression, anxiety and hopelessness which were associated with poor adherence to 
ARVs (R. Lee, Kochman, & Sikkema, 2002). The UNAIDS report on internalised stigma 
explains that this form of stigma Can affect family members and care givers who may also 
have internalised feelings of shame, fear or blame (UNAIDS, 2006) and this may 
consequently affect adherence especially in the case of adolescents who need care giver 
support. 
2.11.4.3 Other illnesses or comorbid conditions 
In all age groups, people living with HIV have an increased chance of chronic complications 
and comorbidities, such as non-communicable diseases and mental, nervous and substance-
use disorders(WHO, 2011). This WHO write-up further explains that, these conditions may 
be pre-existing, HIV -associated or due to ageing. A study by Gallant showed that 6.7% of 
patients on treatment had developed cardiovascular events while 31 % had 
hypertension(Gallant, Hsue, Shreay, & Meyer, 2017). These comorbidities affected ARV 
treatment choices and adherence to the medications. A study by Cantudo revealed that the 
concurrent use of ARV medications with other drugs to treat comorbid conditions affects 
adherence to ARVs(Cantudo-Cuenca, Jimenez-Galan, Almeida-Gonzalez, & Morillo-
Verdugo, 2014). 
A major opportunistic infection associated with HIV is tuberculosis. It has been shown that, 
among people living with HIV, the probability of contacting TB is increased (Clumeck, 
Pozniak, Raffi, & Committee, 2008). Evidence shows that ARV treatment can have a 
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significant toll on HIV and TB related morbidity and mortality in co-infected patients; as 
the simultaneous treatment of both ailments increases the pill burden (Dean et al 2002) in 
(Gebremariam, Bjune, & Frich, 2010). As a result of these complexities with medications 
and the added pill burden, HIV patients who are on TB treatment may experience lower 
adherence to treatment of both ailments. Given that adherence to ARV drugs, TB treatment 
and other opportunistic infections is key in achieving treatment success, it is necessary to 
assess how the presence of these comorbid conditions could affect adherence among 
adolescents. 
One of the patient factors that could affect adherence is losing the pills. The pills could be 
lost in travelling or as patients struggle to hide them in order to ensure their privacy. Loosing 
pills has not been widely studied as a determinant given that existing literature on this 
subject was rare. This study has therefore assed the effect of pills lost as a determinant of 
adherence. The other patient factors are being busy, waking up early and not understanding 
treatment regimen. These factors have also not been widely studied and their effect on 
medication adherence among adolescents were given a chance of assessment in this study. 
2.11.5 Other factors 
Adherence is a complex issue and has a litany of factors that affect it. Having discussed 
factors relating to the patient, health system, socio-cultural and demographic determinants, 
there are still other factors that could also determine how an adolescent adheres to treatment. 
Some other factors that could influence adherence include pill burden, being aware of HIV 
status, no overall improvements in health, financial constraints, forgetting to take 
medications stigma and discrimination. These have been discussed below. 
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2.11.5.1 Stigma 
Stigma has been defined as a negative reaction to a situation which could be for example a 
physical deformity, a group of signs or symptoms as well as a behaviour in an individual 
that is believed to be undesirable or discrediting in a social setting (Goffman 1963 in 
(Martinez el 01.,2012). HIV related stigma is consist of all undesired attitudes, perceptions, 
negative beliefs attached to people who have HIV I AIDS as well as toward their families, 
friends and networks (Martinez el 01., 2012). A lot of the existing studies have noted that 
stigma remains a major fact of life for people living with HIV I AIDS in sub-Saharan Africa 
and referred it as "the central to the global AIDS challenge" as the HIV disease (Mann 1987) 
in (Fido. Aman, & Brihnu, 2016). People experiencing HIV stigma report a range of 
negative effects. such as losing their source of livelihood or job, segregation from their 
normal communities and being unable to fully participate as a productive member of the 
community (Visser, Kershaw, Makin, & Forsyth, 2008). This in some cases causes anger, 
the zeal to revenge and depression which can cause the individual not adhere to 
treatment(Fido et 01., 2016). 
Amongst HIV positive patients, those reporting stigma have a higher chance of non-
adherence compared with those who are not faced with stigma (Rintamaki, Davis, 
Skripkauskas, Bennett, & Wolf, 2006). A similar study among youth also showed that the 
fear taking drugs in the presence of family, friends to avoid rejection also negatively affected 
adherence(Rao. Kekwaletswe, Hosek, Martinez, & Rodriguez, 2007). Furthermore, findings 
from a study by Martinez also had stigma predicting poor adherence and in this case among 
adolescents(Martinez et 01., 2012). In a related study in Nigeria, stigma was shown to 
influence adherence significantly, as patients experiencing stigma and discrimination 
reported lower adherence levels (Omosanya, Elegbede, Agboola, lsinkaye, & Omopariola, 
2014) . In addition • sti gma, dlsc·nm·m·a·tlO n and disclosure were also shown in Uganda to 
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correlate with suboptimal adherence (Nabukeera-Barungi et al., 2015). Kahema and his 
team in Northern Tanzania revealed that patients experiencing stigma had a higher odds 
(2.16) of non-adherence (Kahema, Mgabo, Emidi, Sigalla, & Kajeguka, 2018). However, 
other studies have reported otherwise showing that stigma does not affect adherence to 
medications(Mao, Li, Qiao, Zhou, & Zhao. 2017). 
2.11.5.2 Forgetting to take medications 
Simply forgetting to take medications is a reported problem of many HIV patients as shown 
by a systematic review study(Mark, 2017) where it was the main factor affecting adherence 
as shown in majority of the studies. Additionally, forgetting to take medications also hinders 
adherence as was reported in a study in Ghana (Ankrah el al., 2016). A study among 
pregnant women also showed that forgetting to take medications was related with poor 
adherence (Zahedi-Spung, Young, Haddad. & Badell, 2018). Similarly, HIV patients on 
ARV treatment in Ghana indicated that, not being reminded or having a method of drug 
reminders was causing them to forget medication and this was shown to significantly affect 
adherence (Prah, Hayfron-Benjamin, Abdulai, Lasim, & Nartey, 2018). The authors of this 
study advocate the use of medication prompts among HIV positive patients in a bit to 
improve on adherence. 
2.11.5.3 Financial constraints 
Globally, HIV drugs are given free of charge. However, there other associated cost of 
treatments as patients have to frequently visit the hospital for drug refills, perform routine 
laboratory exams and follow advice regarding their diets accordingly (Abanem & Bongfen, 
2017). According to Wasti and others, associated treatment costs of HIV have a significant 
effect on adherence (Wasti et al., 2012). Another study in the Niger Delta in Nigeria 
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reveaJed that the associated costs ofHIV treatment was associated with a reduced adherence 
(Nwauche, Erhabor, EjeJe, & Akani, 2006). 
2.11.5.4 Pill Burden 
ARV drugs are taken on a daily basis and this is expected to be lifelong. Antiretroviral 
therapy (ARn is a combination treatment containing three or more antiretroviral 
molecules(Sutton, Ahuja, & Magagnoli, 2016). Multiple tablet regimens require two or 
more tablets per day and the higher pill burden is associated with lower adherence 
(Bangsberg, Ragland, Monk, & Deeks, 2010). This has been further shown in a number of 
studies where adherence is higher in patients with once daily and single tablet regimens 
(Fielden et 01.,2008; Juday, Gupta, Grimm, Wagner, & Kim, 2011). According to a meta-
analysis of randomised control trials by Nachega and others, adherence was significantly 
associated with once daily regimen. However this was not shown to translate into better 
treatment outcomes (Nachega et 01.,2014). Similar findings were observed in a study by 
Carter 2014 as adherence was higher in patients taking one daily regimen compared to those 
on twice daily regime. There was however no difference treatment outcomes comparing one 
daily to h\;ce daily regimens(Carter, 2014). Furthermore, some findings suggest that, the 
simplification of treatment regimens could also help improve adherence to ARV treatment 
(Langebeek et 01.,2014). 
The other factors of treatment adherence; being away from home and improvements in 
overall health are also possible factors that can affect adherence. These factors have been 
assessed in this study to ascertain their role in mediating adherence among adolescents. 
The determinants of adherence discussed here appear to be interwoven as one adolescent 
can experience a multitude of these factors at a time. The determinants of adherence have 
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been seen to vary from context to context and may even vary across age groups. Although 
the determinants of adherence to ARV  have been given global attention as seen in the 
literature of published articles, there exist a paucity of information as to the determinants of 
adherence in the selected study area especially among adolescents. 
2.12 Care of adolescents and health facility preparedness towards providing ART 
services 
2.12.1 Care of Adolescents with HIV at the facility level 
The developmental stage of adolescents makes caring for them challenging and because the 
adolescents approach to the disease is different, their care is also supposed to be different 
form that offered to adults(Elaine Gross, 2004). 
The World Health Organisation (WHO, 2013a) has defined standards for quality healthcare 
for adolescents. The purpose of the national guidelines for the quality of health care delivery 
is to enable stake holders in health to improve the quality of care offered to adolescents so 
that the care is made accessible and available to these adolescents to improve on their 
general well-being (WHO, 2013a). The following steps are recommended guidelines from 
NACO 2013 for ALHIV(NACO, 2013); 
Step I: Establish rapport and relationship of trust with the adolescent. This can be done by: 
- Encourage peer involvement and help to identify treatment support buddies. 
- Encouraging disclosure. 
- Developing an individualised treatment plan for ARV that fits into the individual's lifestyle 
as well as identifying possible reminders. 
- Assessing individual's readiness for ART. This could be rated in terms of the individual's 
preparedness or ability to attend clinic regularly and not skipping appointments as well as 
taking other treatments such as cotrimoxazole and TB treatment 
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_ In cases where the adolescents has challenges in adhering to regular doses adherence 
counselling should be reinforced. The possible challenges to adherence could be listed and 
strategies developed together with the adolescent to overcome these barriers 
_ Dietary requirements with ARV drugs should be adequately explained as some of the 
drugs are taken with or without food and some may need more water for intake 
- The possible medication related medication side-effects of the drugs have to be properly 
explained and understood by the patient before beginning the ART treatment 
- The use of other drugs such as herbal or traditional medications, could interact with ARV  s. 
There is therefore the need for adequate counselling on the possible consequences of some 
of the traditional medicines on the health of the patient as they might have antagonistic 
properties with the ARVs they are taking 
- The patient should be educated on the need of regularly attending scheduled clinic visits 
adherence monitoring and other factors relating to treatment 
- The facility should have a proper follow-up system where patients can be called to be 
reminded of their hospital visit. In cases where a patient failed to meet up with an 
appointment, they should be called or visited at home 
Step 2: Counselling - which is should be in one or more individual sessions 
-The patient should be helped to explore their feelings. The patients have a varied number 
of social issues ranging from family, to relationships, job which can hinder adequate 
adherence. These should be discussed, and possible solutions suggested on the way forward 
-Issues relating to privacy should also be discussed. Some of the patients lack privacy and 
may not even have a proper and safe place to keep medications at home. Given that the fear 
of others knowing status is a possible reason for poor adherence, challenges relating to 
privacy should be identified and recommendations made to enable the patient to manage the 
situation. 
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-The patient should have a significant other whom he/she can confide in as they may need 
encouragement and support from these when need 
-The health care provider should also asses the fmancial status of the patient as lack or 
inadequate finances may cause some patients to skip hospital appointments. If possible, the 
patient could be assisted to develop secondary support systems for themselves 
Step 3: Solving practical problems and creating a treatment plan 
Some of the common questions that could be asked include; 
-Where will the medication be kept at home? 
-At what time will the medication be taken? 
-What will make the remember to take medication or who will be there to remind himlher 
to take medications in case it is forgotten 
-What will happen in situations where the normal routine is interrupted? This could happen 
for example during travel. 
All these issues must be carefully addressed in a one on one counselling session with 
adolescent and guardian. In some cases, these concerns may not be sorted in a single session 
and will hence require multiple counselling sessions till the adolescent is comfortable with 
the desired treatment plan. 
Generally, studies have shown that adolescents generally avoid health services if they are 
not adapted to be adolescent friendly (Atuyambe, Mirembe, Annika, Kirurnira, & Faxelid, 
2009). Adolescent friendly health services (AFHS) according to the WHO standards should 
be characterized as follows: 
Equitable: for all adolescents without any exceptions and they are expected to have access 
to the health services that are essential for them 
Accessible: Adolescents are able to have the services that are provided for them. 
Acceptable: The health services are offered in ways that meet the desires of adolescents. 
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Appropriate: The proper health services that adolescents need are provided. 
Effective: The right health services are provided properly, and have a positive impact on 
the health of adolescents (WHO, 2015). 
Apart from having adolescent friendly health services, health care system are often lacking 
in the equipment needed to provide appropriate and effective care that meets the needs of 
these adolescents especially those with HIV(WHO, 2015). In many countries of Africa in 
particular, there is inadequate training and experience for health workers who care for 
adolescents as some of them become judgemental especially in issues relating to sex and 
this could hinder rapport with the adolescent and even cause them not to attend the facility 
subsequently (WHO, 20 13a). There is therefore a need to empower health workers and 
provide them with the necessary tools to care for ALHIV to improve their treatment 
outcomes. 
According to the National Guidelines on the Management of HIV in Cameroon (2015), 
disclosure can begin at age 10 years but if the adolescent encounters difficulties in adapting, 
it is better to wait until it is more comfortable to do so. The guideline gives recommendations 
for starting ART in adolescents according to the WHO 2016 guidelines (Tablel). 
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Table I Recommendations for starting ARVs in adolescents and Adults in Cameroon 
151 Line Alternatives 
-Tenolam Efavirenz -Duovir Nevirapine 
(TDF 13TCIEFV) (AZT/3TCINVP) 
-Duovir Efavirenz 
(AZT/3TCIEFV) 
-Tenolam Nevirapine 
(TDF/3TCINVP) 
2nd Line 
Atazanavir-ritonavir (AZT/3TCIA T V Ir) 
3rd Line 
Darunavir!DolutegravirlEtravine 
(2INT !DR V! DTGIETV) 
2INT/DRVI RALIETV 
Source: National Guidelines for the Prevention and Management of HIV in Cameroon 
2016 
2.12.2 Health facility preparedness in Providing ART services to adolescents with HIV 
Globally, health care systems are still making progress towards having adolescent friendly 
health services to provide quality care for adolescents. Most of the HIV services provided 
are insufficient and do not meet the needs of adolescents (WHO & UNAIDS, 2015). In 
Cameroon there is a National Treatment Guideline for ART, which was first published in 
2001, simplified in 2003 and later updated in 2006 and 2010. It was updated in 2015 to 
include the WHOs' 2013 recommendations and include a section on management of 
adolescents. The present guideline, which was updated in 2017, includes the WHO 2016 
recommendation, test and treat strategy for all or treat all, and is recommended for use in all 
health facilities in Cameroon providing HIV treatment and care. 
According to the WHO guidelines for HIV services, adolescent friendly comers in health 
facilities should be secured, private and a away from sources of stigma so that adolescents 
and health care providers can have proper interactions that allow them offer health that is 
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acceptable, effective and desirable for the adolescent (Aditi, Teltschik, & Davies, 2015). 
From these guidelines therefore, health facilities providing ART to adolescents are expected 
to have a separate adolescent comer and a written and regularly reviewed adherence strategy 
for adolescents (WHO, 2007). 
Facility preparedness towards care of adolescents on ARV can be accessed using the John 
Snow Inc (lSI) (2003) tool, which is the standard tool at the moment. The JSI tool looks at 
\arious aspects of care such as leadership, management of ARV drugs, programme 
protocols, experience and staffing and laboratory capacity. For leadership, the health facility 
should have a leader with vision and some experience in health care management. It also 
looks at the model of care which has been identified for use in the facility. In the case of 
management of ARV drugs, the facility ought to have staff with experience or training on 
ART, comprehensive services, physical space for drugs and for consultations with 
confidentiality and community involvement. For ART protocols, the health facility should 
own and use the National treatment protocol, a management information system and a 
system for monitoring and evaluation. For experience and staffmg, the health facility should 
have experience staff and should also have a plan for training and retention of staff. Finally, 
lor laboratory capacity, the facility should provide access for minimum laboratory test as 
per the WHO or national protocol guidelines. The laboratory should also maintain quality 
standards with a system for quality assessment. 
In Cameroon, there are treatment guidelines for HIV treatment which are inclusive of 
adolescents. Some health workers have also received training for care of adolescents to 
improve care but there is sometimes lack of continuity of care especially when the trained 
focal person is transferred (Ako-Egbe, 2018). Adolescents seeking HIV care deserve 
standard care which appeals to them and gives them more reason to always return to the 
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health facilities. This is the case because adolescents are more likely to be adherent and 
present with better treatment outcomes if they returned in care through provision of quality 
services (Babatunde et al., 2015). There has been very little literature assessing the level of 
facility preparedness towards care of adolescents in Cameroon. Given the peculiar 
importance of standard of care as it may affect adherence to ARV s in adolescents, this study 
has examine the level of facility readiness to receive HIV positive adolescents. 
2.13 Strategies to improve adherence to ART among adolescents 
Studies from both high and low income countries show that health services delivery for 
adolescents has gaps, is inconsistent and with varying quality standards (WHO & UNAIDS, 
2015). It is therefore the role of health care providers to make more efforts in providing 
appropriate and adequate care to adolescents that helps them to overcome some of the 
challenges and barriers they face as they the take medications. The providers should also 
encourage and enable adolescents to make a commitment to treatment 0 as to improve 
treatment outcomes. 
Despite the modest progress made in HIV treatment, there is certainly the need to scale up 
adherence by identifying and mitigation barriers to adherence. Even though there are 
mUltiple strategies to enhance adherence depending on the setting, these authors offer varied 
suggestions that health care providers could consider. These approaches include: 
The patient should always be as sed of readiness to begin treatment before treatment 
I started and should be closely monitored. In case of treatment failure a possible 
substitute could be made 
• The health care provider together with the patient should identify the possible 
barriers to medication adherence and hence support the patient to identify possible 
solutions to the problems identified. The patient could also be helped to have social 
support network or system 
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• Drugs should always be provided as per the treatment guidelines and where it 
permits, once daily regimens should be given preference over the others 
• Social factors such as drug abuse and alcohol should be discussed as well as the 
consequences on the health of the patient 
• Patients should be monitored for depression and other mental illnesses and offered 
adequate support as required. 
From another perspective, a recent study carried out in Rural Zimbabwe assessed the 
effectiveness of community adolescent treatment supporters (CATS) in improving linkage 
to care, retention rates, adherence to ART and mental well-being. A randomised trial among 
adolescents 10 to 15 years old living with HIV was conducted (Willis et al., 20 I 9). Based 
on a randomised trial, the study reported a significant increase in the factors of adherence 
such as confidence, self-esteem, self-worth and quality of life in the intervening group 
showing 3.9 times adherence higher than in the control arm (Ibid). It was revealed in this 
study that participants receiving the intervention showed a substantial improvement in 
adherence to ARV from 44.2% at baseline to 71.8% at the end of the study period 
According to these authors, the observed difference in adherence was a result of the use of 
the treatment supports in the community. Furthermore, the involvement of CATS with the 
health care providers offered adolescents the opportunity of expressing their worries and 
even make proportions of solutions to some of these problems. The community treatment 
supporters are well trained to support adolescents on ARVs. In this respect, the study 
recommends that community interventions that are managed by other adolescents should be 
used as means to improve on adherence among them. This should, however, be done after a 
similar study is carried out in other areas to ascertain these contributions of CATS. 
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Furthermore, the initiation and use of adolescent friendly health services has improved 
acceptability and retention rates for adolescents especially those living v"ith HIV (WHO 
2015). According to Asire and others in 2017, the use of adolescent friendly comers in health 
facilities that offer services at acceptable hours making provision for other health delivery 
settings such as schools and social centres, and mobile services that insure confidentiality 
can adequately improve their adherence ability (Asire. 2017). Similarly. attractions such as 
accommodating and friendly health workers, entertainments such as Television screens, 
motivations like snacks and transport reimbursement also impact adherence positively 
(ibid). 
Furthermore. the use incentives has also been shown as a means of improving adherence. A 
randomized control trial done in California by Sorenso and others revealed that the use of 
incentives to motivate HIV positive patients improved adherence. In this study, the 
participants were randomly assigned to two groups, control and intervention. The control 
group received health education on adherence and vouchers each time they took medications 
while the control received only health education. After 12 weeks, adherence was compared 
between the two groups and the intervention group had 78% compared to 56% in the control 
group (Sorensen et 01.,2007). 
Another strategy that has been tried to improve adherence is the use of psycho-education. 
One of such interventions was carried out by Tudra and to assess the effect of Psycho-
education on medication adherence. The intervention arm received counselling relating to 
dealing with psychological issues while the control group received the normal routine 
counselling from health care providers. After 48 weeks, adherence was measured between 
the two groups and the intervention group reported an adherence of 94% compared to 69% 
in the control group (Tuldra et al., 2000). 
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Additionally, the use of SMS (short message services) has also been shown as a means of 
improving adherence to ARVs and even other medications like tuberculosis treatment 
(Bediang, Stoll, Elia, Abena, & Geissbuhler, 2018; Sherman et al., 2018). One of such 
interventions is the randomised control trial by Bediang in Cameroon that used SMS as an 
intervention to assess its impact on adherence. The patients in the intervention arm received 
daily reminders to take medications while those on the control arm did not receive any. The 
results of this randomized controlled trial indicated an improved treatment adherence among 
patients who received reminder messages during their treatment for tuberculosis (TB) than 
those who did not(Bediang et ai., 2018). Additionally, in a qualitative study among patients 
receiving treatment for HIV in the United State of America, those who received daily 
reminder messages adhered more to treatment than those who did not(Sherman et al., 2018). 
Another randomized control trial by Pop-Eleches and others in Kenya also suggested SMS 
as an important tool for improving adherence in resource limited settings in Africa(Pop-
Eleches el al., 2011). Moreover. a systematic review by Amankwa et ai., 2018, revealed 
that, scheduled messages to patients on ARV treatment made them adhere better than those 
who received no reminder messages (Amankwaa, Boateng, Quansah, Akuoko, & Evans, 
2018). 
However, the use of SMS in adherence has not had consistent findings. A study by 
Mbuagbaw in Cameroon 2011 had contradictory findings. In this study adherence to ARV 
was compared between two groups- one group receiving weekly SMS reminders to take 
medications and the other group did not receive any reminders. Adherence was compared 
between the two groups at 6months and there was no difference in adherence (Mbuagbaw 
et al., 2011). 
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Despite the existence of the above factors in mitigating the barriers to ART adherence, 
Scanlon and Vreeman (2013) in their study on "Current strategies for improving access and 
adherence to antiretroviral therapies in resource-limited settings" however, explains that 
individuals living with HIV continue to face challenges as they adhere to treatment. This is 
justified by the fact that there are still few evidence based interventions that can inform 
healthcare professionals and stakeholders who are at the forefront of adolescent care. 
(Vreeman, Gramelspacher, Gisore, Scanlon, & Nyandiko, 2013) 
The limited strategies to mitigate barriers to adherence is more common among vulnerable 
groups including women, children and adolescence and other high risk popUlations. Given 
that the strategies to improve on adherence vary within contexts, there is the need for the 
current study explore ways, among others, through which adherence can be scaled-up 
especially among adolescence that constitute a vulnerable group of persons especially in a 
developing country like Cameroon. 
Social support services for adolescents with HIV 
HIV support services are the are non-clinical services and the treatment of co-morbid 
conditions that are used together with ARVs to improve quality of life and reduce HIV and 
AIDS deaths (UNAIDS, 2016d). According to this report by UNAIDS, treatment support is 
necessary for the following reasons; support adherence to treatment as a means of improving 
viral load suppression and other treatment outcomes, for improved well-being and 
preventing further diseases spread; to also prevent the occurrence of other illnesses and 
properly manage them if they occur and coping the difficulties of living with the virus. 
Social support in HlV care is also defined as the assistance people receive, or perceive to 
have received from their social links (Matsumoto et al., 2017). The types of social support 
vary and range from emotional support which could be offered in terms of empathy, 
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informational support which could be given through suggestions and advice and other 
physical support in terms of fmancial assistance and sometimes food or other materials 
(Cohen 1994) in (Matsumoto et al., 2017). According to these authors, social support could 
come from, family members, friends, neighbours and colleagues. Evidence from some 
studies have shown that social support systems improve AR V treatment outcomes among 
HIV positive persons on ARVs (Umberson & Karas Montez, 2010; Maman, van Rooyen, 
& Groves, 2014; Rouhani et al., 2017) 
According to the International AIDS Society (lAS), adolescent peer support models have 
demonstrated outcomes of improving retention, virological suppression and resulting in 
good psychosocial well- being (lAS, 2016). FurthernlOre, a study among HIV infected 
adolescents in Kenya showed that the use of a support group improves on the treatment 
outcomes(Levy et al., 2016). In Cameroon, a few studies have been done to assess the role 
of social support services in HIV care. One of such is a study in the Muyuka district that 
showed that community participation improved retention rates of HIV positive persons 
(Constance, Ngouakam, Thomas, & Nsagha, 2019). Another study in Cameroon also 
revealed that the decentralisation of HIV care to involve social support networks could 
improve quality care and adherence to ARV treatment(Boyer et aI., 2011). 
The role of the Care giver in adolescent care 
As indicated in the background of this thesis, there have been significant advances in the 
treatment ofHIV the world over, thus transforming the disease into a life time infection that 
can be managed. Most of these advances are attributed to the improvements in anti-retroviral 
treatments. One of the increasingly recognized contribution to enhanced adherence to HIV 
treatment is related to the quality of caregiving. This is particularly important especially 
with HIV infected children and young adolescence whose adherence to ART can be 
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significantly determined by the caregivers' beliefs in necessity of treatment (Abongomera 
et al., 2017). 
Despite the potentials of caregivers to enhance HIV patients' adherence to medication, 
Mokwele and Strydom indicate that experiences of and barriers encountered by volunteers 
and community workers involved in HIV care to ensure that patients adhere to treatment 
has not been adequately documented. (ARn (Mokwele & Strydom. 2019). Nevertheless, 
some authors have equally underscored the importance of caregiving in HIV adherence in 
general and children, adolescence and youth in particular (Gichane et al., 2018) 
In an earlier study, Beals et al. examine the role played by women in promoting adherence 
to HIV medication among HIV -infected person in general and husbands and older sons in 
particular (Beals, Wight, Aneshensel, Murphy, & Miller-Martinez, 2006). In this study, 
caregivers are understood to be important in the patients' treatment adherence as they 
constantly remind them to take medications and to attend clinics as well. Other roles 
observed to have been played by caregivers in this study are; indicating when the patient 
has difficulties with medications such as side effects, treatment failure and other issues 
relating to the patient's ability to adhere to medications. 
In some other context where HIV stigma is still rife as in some parts of sub-Saharan Africa, 
caregivers are largely involved in dealing with stigma in order to improve adherence of 
family members especially young people. McHenry et al., in a study in Kenya among care 
givers of children and adolescents with HN gives the challenges they face especially 
relating to HIV stigma (McHenry et al., 2017). The study reports the negative and wrong 
perceptions about HIV held by community members about HIV transmission and 
prevention. This often gave rise to stigma which causes reduced or loss of social networks, 
economic support and could even give a chance to depression, mental illness or internalised 
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stigma. According to the findings of the study, stigma was the main reason for non-
disclosure of status, poor adherence depression and other psychological problems. 
In or order to establish the importance of enhancing effective caregiving, some authors have 
sho\\;n that social support is an vital aspect that could be used to improve on the physical 
and psychological health of caregivers and children affected by HIV I AIDS, especially in 
areas of the world where the disease is endemic such as in the developing world (Casale & 
Wild, 20(3). In a critical review aimed to empirically determine the evidence of the effects 
and processes linking support to caregiver health among HIV/AIDS-affected Care-Child 
dyads, these authors (Ibid) show the importance of social support for health among this 
population. However, the lack of evidence on the effects of social support on caregiving and 
patients in developing world makes it challenging to generalisations based on this study. As 
indicated by these authors, there is equally a need for further research on the psychosocial 
factors explaining the observed results. 
Gichane. el al. (2017) also note that youth living with HIV in sub-Saharan Africa are 
confronted with numerous adherence challenges. As many of these youths acquired the virus 
vertically, many of them are now orphans, making home-based care giving a daunting 
challenge as well. In their qualitative study of HIV infected orphans aged between 13 and 
24 in Tanzania, the authors noted significant variations between paternal orphans cared for 
by their biological mothers on the one hand and maternal orphans cared for by their 
grandmothers on the other hand. Key adherence supports for these groups of orphans were 
centred on assisting the infected orphans in taking medication and attending clinic. 
However, double orphans in this study did not report support to adherence, indicating the 
lack of home care giving (Gichane et al., 2018). The understanding of this kind offamily 
context of orphans living with HIV is thus imperative in efforts to improve ART adherence. 
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In a phenomenological study on the challenges and views of community caregivers with 
regard to antiretroviral treatment, Mokwele and Trydom emphasize that as a contribution to 
dealing with the effects of HIV and AIDS which have had a devastating effect on some 
communities in South Africa and recommended an improvement in the social support 
structures for patients who are on ARV (Mokwele & Strydom, 2017). This can be done by 
exploring the challenges experienced by community caregivers in order to benefit from their 
views (from their everyday life and experiences) and hence design community-based 
interventions aimed at improving adherence of patients to ART. This study explored and 
described the perspectives of three established community caregivers' organisations in 
Potchefstroom, South Africa, namely, Bambanani Youth Project, Baptist Children's centre 
and Hospice Emanuel Loving Angels. Most of the care to HIV and AIDS patients are done 
by these community health givers who were the key participants in the study. 
Much of caregiving to HIV infected persons often done by relatives and this is detennined 
by a range of factors such as care givers' income, gender, and age among other factors. 
Generally, those without steady occupations have been observed to be the principal 
caregivers to HIV infected persons. In a cross-sectional study on adherence to antiretroviral 
therapy among Brazilian HIV-infected children and their caregivers in Salvador, Ricci and 
his team indicated that caregivers were largely women who did not have a fixed salary, had 
formal education of less than four years, and were mostly relatives of the children between 
I to 12 years considered in the study (Ricci, Netto, Luz, Rodamilans, & Brites, 2016). These 
socio-demographic and economic characteristics of caregivers were observed to be 
significantly associated to 4-day children's adherence ~ 95% (p < 0.05). The role of 
caregivers is particularly fundamental to children and younger adolescence given that 
successful treatment ofHIV-positive children also needs an adherence level of at least 95% 
as is the case in adults. In the circumstances therefore, caregivers are often expected to 
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pharmacy refill on behalf of the children, taking them to clinic as well as improving on 
nutrition. 
A similar study among caregivers ofHIV children and adolescents in Ethiopia reported that 
the main characteristic of the caregivers which had an effect on patients' adherence were 
their marital status and age (Eticha & Berhane, 2014). According to the testimonies and 
experiences of caregivers in this study, children whose caregivers were unmarried and 
married had a higher chance of adhering to their ART treatment more than those whose 
caregivers were divorced/separated. In like manner, children whose caregivers' were 
between age 25 and 44years also showed a higher adherence compared to the others. The 
care givers reported medication related side effects, pill burden, difficulty in swallowing the 
pill and depression as some the difficulties that could cause the children to miss medications. 
Tht: importance of caregiving to HIV treatment adherence is further justified by the fact that 
caregivers (given that they are adults) are the ones who can best present the physiological, 
social and economic determinants of HI V treatment adherence by children and adolescence. 
In their study on the "Factors related to antiretroviral therapy adherence in children and 
adolescents with HIVIAIDS in Cuba,"{Castro et al., 2015) explained the challenges faced 
by caregivers which could potentially undermine adherence if not addressed. As reported 
by caregivers in this study, poor adherence was attributed to social and psychological factors 
including the fact that the caregivers were overburdened especially if they were also sick, 
insufficient family support and in some cases untreated mental issues. The care givers in 
some situations even allow the children to their own medications even when they are not 
matured enough to take over the treatment responsibilities. The study hence shows the vital 
role of the caregiver and family support for treatment success in children and adolescents 
living with HIV/AIDS. 
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Transitioning adolescents to adult mv care 
Health care transitioning in HIV care is defined as the purposeful movement of an 
adolescent from child-centred to adult centred-care(Tanner e/ al., 2016). The treatment 
outcomes of adolescents in adult care are largely dependent on how well they are prepared 
for transitioning to adult services. The adolescents are supposed to be empowered and 
supported to acquire individual self-management skills in order to adapt to the change (Yi 
et al., 2017). Some studies have revealed that, moving to adult care is a critical determinant 
of adherence to ARVs and treatment outcomes(S. Lee & Hazra, 2015). Evidence also has 
it that, transitioning to adult HIV care is associated poorer treatment outcomes such as loss 
to follow up, high viral loads and reduced immune recovery (Judd, Sohn, & Collins, 2016). 
Therefore, the transition process among adolescents should be informed by the contextual 
issues facing the adolescents while focusing on the social support system that will enable 
the adolescent transition successfully (Yi et al., 2017). 
According to the World Health Organization, moving an adolescent to adult care should be 
done when the done when the individual is aware of the status, has basic knowledge on this 
health care, understands the disease and the regimen and has acquired skills to manage their 
own health. (WHO, 2013a). Transitioning to adult care is linked with a number of barriers 
which could be from the individual or from the health facility. Some of the individual 
barriers include; stigma, drug abuse, mental diseases, attachment to a paediatric healthcare 
provider and phobia for adult clinics. The health facility factors range from inadequate 
training and experience of staff in adolescent health issues and a gap in communication 
between children and adult HIV care services (Straub & Tanner, 2018). 
In other to have a safe transfer from adolescent to adult care, there is the need for detailed 
and context specific guidelines that can bridge the gap between paediatric/adolescent and 
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adult clinics to provide care that is not only of quality but continuous and desirable for the 
new adult who is being transitioned as this likely to make treatment outcomes better (Tanner 
el al., 2017). Moreover, this study reiterates that, adolescent and adult clinic involvement is 
necessary given that it reduces gaps in care, provides continuous care that is well 
coordinated and supports the new adult to adapt to the adult services. 
Transitioning to HIV care can also be facilitated by developing formal, written transition 
policies (involving both paediatric and adult teams) . training staff in adolescent 
development, employing strategies (depending on the context) to ease physical connection 
of adolescents with adult care services, providing support to children and adult clinics, 
empowering the adolescents with life skills and health management tips to support 
adherence to medication and open discussions between paediatric and adult health staff 
(Straub & Tanner, 2018). 
2.14 Global Response to tbe HIV epidemic among adolescents 
Earlier on. adolescents were either part of the children or adult health services but recently 
it has been recognised that their health requirements are different from those children or 
adults (Armstrong el al., 2018). The prominence of adolescents in the health response is 
seen in recent global health and HIV programs (ibid). Some of these include the United 
Nations Global Strategy for women, Children and adolescents. This Global Strategy for 
2016-2030 seeks to achieve the right to the highest attainable standard of health for all 
women. children and adolescents. It is believed that by 2030 this target would have been 
achieved. In addition, another fast track agenda was developed in 2015 jointly by UNAIDS, 
PEPF AR. WHO. UNICEF and the Elisabeth Glacier foundation. This one was called start 
free, stay free and AIDS free. It has a number of objectives; 
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_ Eliminating incidence ofHIV infections in children (aged 0-14) by reducing the number 
of children newly infected yearly to less than 40 000 by 2018 and 20 000 by 2020. 
_ Providing ARV treatment to 95% of all HIV positive pregnant women by 2018. 
-Decreasing the incidence of HIV infections among adolescents and young women aged 
10-24 to less than 100 000 by 2020. 
_ Increase voluntary medical circumcision for HIV prevention to 25 million men by 2020, 
with a focus on young men aged 10-29. 
_ Provide antiretroviral therapy to1.6 million children (aged 0-14) and 1.2 million 
adolescents (aged 15-19) living with HIV by 2020 (P. UNAIDS, WHO, UNICEF, Elisabeth 
Glacier Foundation 2015). 
Furthermore, another project was launched by UNAIDS and UNICEF in February 2015, 
called "ALL IN" to end adolescent HIV by 2030. This program was launched in a bit to 
stimulate global action towards HIV and a population that were largely neglected in the 
global AIDS response, that is, adolescents. It is focused on the 28 countries that contribute 
to 86% of all adolescent HIV and seeks to bring adolescents into the limelight as the struggle 
to end adolescent HIV continues (U. UNAIDS, 2016). The ALL In project has three main 
objectives: 
• Reduce incidence of HIV infections among adolescents by at least 75 % 
• Reduce AIDS-related deaths among adolescents by at least 65% 
• End stigma and discrimination 
2.15. Measurement issues in adherence research 
Inadequate adherence to antiretroviral treatment leads to therapeutic inefficacy for patients 
and programmes and clinical failure as well as emergence and transmission of resistant 
viruses (Kouanfack et al., 2008). Accurate measurement of antiretroviral adherence is 
therefore essential for targeting and monitoring interventions to increase adherence and 
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prevent emergence of drug resistant viruses (Berg & Amsten, 2006). There are varied 
methods of measuring adherence with advantages and disadvantages depending on the 
context and the time. In the absence of directly observed therapy (DOTS), the levels of 
adherence can only be estimated using other available measures (Gill, Hamer, Simon, Thea, 
& Sabin, 2005). Some of the available indirect methods of measuring adherence include; 
self-reports, electronic drug monitoring (EDM), pill counts and pharmacy refill records to 
obtain medication possession ratio(Berg & Amsten, 2006). Adherence can also be measure 
directly by measuring metabolites including detection of drugs in plasma. These are 
reviewed below (ibid). 
2.1S.1 Self-Reporting 
Self-report is the most frequently used adherence measure in both clinical and research 
settings because it is easier, flexible, affordable with reduced respondent burden and also 
safes time (Berg & Amsten, 2006). In this method, respondents are usually asked to recall 
the number of doses skipped within a defined period and adherence is then calculated 
(Simoni el at., 2006). It may also include qualitative estimates of overall adherence, 
reporting the number of days of perfect adherence in the past week or month, recalling when 
the participant or patient last missed a pill and determining the number (or proportion) of 
doses (or pills) missed (or taken) over a chosen recall period. 
The disadvantage of this self-report is the ceiling effect, which is usually due to question 
misunderstanding and recall bias. For instance, a participant could be asked about the 
number of pills missed and helshe understands to pills, this way adherence will be 
o\erestimated (ibid). Furthermore, it easier to remember accurately events that happened 
than those that were forgotten hence there is a chance for adherence to be over-estimated 
due to recall bias, (Joslyn, Loftus, Mcnoughton, & Powers, 2001). The use of Computer 
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Assisted Self-Interview (CASI), which can may have an audio attachment to accommodate 
those with low literacy levels, has been shown to improve self-reported adherence. 
However, there is no evidence to proof the impact of this method on validity or response 
rate (Johnson et al., 2001). 
2.15.2 Pill counts 
Pill count (counting the pills of patients) is another method of measuring adherence. Pill 
counts is measured based on number of pills taken to the pills prescribed. Hence, if an 
individual is prescribed a medication to be taken as 2 tablets 3 times a day for a week, but 
takes only 2 tablets a day for 2 days, his !her adherence would be 8 / 42 = 19% (Haynes, 
Ackloo, Sabota, McDonald, & Yao, 2008). There are two types: announced and 
unannounced counts. Announced pill counts is done during scheduled patient visits as they 
are asked to bring medication bottles. the pills are counted, and the adherence is calculated 
with reference to the correct start date. The weakness of announcing is "pill dumping", that 
is throwing some pills away. Also, if the start date cannot be determined then it will be 
difficult to calculate the adherence rate. Unannounced pilI counts can be used but some 
patients may view pill counting as intimidating and indicative of mistrust in their self-
reported adherence. Pill count is also very time consuming (Berg & Amsten, 2006). 
2.IS.3 Pharmacy Refill Records 
Pharmacy refill records are used to measure adherence especially in situations where the 
drugs are provided by a single payer. Adherence rates from pharmacy refill records are 
calculated either by comparing actual to expected refill dates or by identifying "medication 
gaps," defined as periods of time during which the patient's supply of medication is assumed 
to have been over (Inciardi & Leeds, 2005). Pharmacy refill records can be used to measure 
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adherence through the medication possession ratio (MPR) and proportion of days covered 
(PDC). 
MPR is calculated as the sum of the days of treatment supplied for all ART prescriptions 
tilled. within the retlll interval divided by the number of days during that same time period 
(Kabore el 01 .• 2015; J. Kim. Lee. Park, Bang. & Lee. 2018). A MPR >95% is usually 
considered adherent. MPR could be more than 100% if patients refill before the medications 
run out (Jamie, 2010). PDC measures the number of days "covered" by a prescription 
divided by the number of days in the measurement period (Wang, Huang. & Traubenberg, 
2013). The Proportion of days covered takes each day in the interval to see if the patient has 
the prescribed drug on-hand (ibid). The PDC provides a more conservative measure 
compared to MPR and avoids double counting days of medication coverage because a day 
is only counted if all medications are available on that day (Jamie, 2010). 
The advantage of using pharmacy records to measure adherence is that, the patients are not 
involved in the measurement and the process takes less time. The main disadvantage is that 
patients can collect drugs but alone does not equal to taking them. Furthermore, pharmacy 
retills are not done on time, patients might be missing doses (Berg & Arnsten, 2006). 
2.1 SA Therapeutic Drug Monitoring 
This is another measure of adherence that measures the level of drug in serum (Berg & 
Amsten, 2006). Low drug level is indicative of non-adherence and virologic failure (ibid). 
It is not ·.. .. idely used as it is expensive and has challenges with standardization. Therapeutic 
Drug Monitoring also measures drug level within 24hrs and hence if announced patients 
can then take their pills and hence the method will over estimate adherence (Paterson, 
Potoski. & Capitano, 2002). 
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2.15.5 Composite Measures 
Some authors have suggested that using composite measures improves sensitivity of 
adherence measurements (Liu et al., 2001; Lam & Fresco, 2015). This implies that two or 
more methods can be used to assess adherence in the same population. The difficulty here 
is which of the methods to combine, how many and even when and where to combine them 
(Lam & Fresco, 2015). 
Adherence could also be measured through Electronic Drug Monitoring (EDM), which uses 
monitoring devices, such as the Medication Event Monitoring System (MEMS). According 
to Gill and others (Gill et al., 2005), EDM is the best surrogate measure of adherence. 
In summary, it is clear from literature that the measurement of adherence is still elusive in 
both clinical and research settings as there are no ideal measures (Adejumo et al., 2014). 
Self-report is most common and easiest to use. It could be improved upon to increase its 
sensitivity and specificity. 
2.16 Pbilosopbical Underpinnings of tbe Conceptual Framework 
Health behaviour theories and models have been used in health programs and interventions 
aimed at improving health outcomes. There are several models that can used to explain and 
describe interventions in HIV care. Some of these models that are widely used include; the 
Social Cognitive Theory (SCT), Health Believe Model (HBM), Beliefs about Medicine 
(BAM) model, the Trans-theoretical model and the theory of reasoned action or planned 
behaviour. The framework for this study was based on the theory of reasoned action or 
planned behaviour. 
The theory of reasoned action was developed by Fishbein and Ajzen in 1975 (Munro, 
Lewin, Swart, & Volmink, 2007). This theory was first known as the theory of reasoned 
action (TRA) and later modified to the theory of planned behaviour. The TRA predicts 
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behaviour from intentions and explains the association between attitudes, beliefs, intentions 
and behaviours that can regulate an individual's behaviour (Adefolalu, 2018). The model is 
influenced by three factors: norms, attitudes and self-efficacy (Fishbein & Ajzen, 1975). 
According to Fishbien and Ajzen, behaviour intention is influenced by an individual's 
attitude towards such a behaviour which is subjective. Self-efficacy is the individual's 
confidence that they can perform a certain behaviour (Adefolalu, 2018). 
This theory has been seen to be beneficial in understanding medication adherence in a 
variety of conditions such as HIV (Vissman, Young, Wilkin, & Rhodes, 2013) in (Rich, 
Brandes, Mullan. & Hagger, 2015). Adherence in chronic diseases requires a specific pattern 
of behaviour, that is, performing the behaviour over long periods of time in order to manage 
the disease as per the recommendations of the health care providers (Sabate & Sabate, 2003). 
Adherence to ARV requires that the individual takes into consideration the beliefs, attitudes 
and intentions that exist within a specified population (Adefolalu, 2018). The conceptual 
framework of the study has been designed to capture adolescents' beliefs, attitudes and 
behaviours (ranging from demographic, socio cultural to other factors) and how these can 
affect ability to adhere to ARV drugs. This therefore entails the designing of measures to 
gauge the intention, that is how likely an individual will adhere to treatment, behaviour 
which measures previous adherence in the population and predisposition towards adherence 
(attitude) (ibid). Hence, a comparison of the results between those who are likely to adhere 
to ART treatment and those who might be non-adherent, will assist in identifying the factors 
that can determine adherence in a particular study population. However, this theory has been 
criticized for being static and not accounting for the effect of behaviour on cognition and 
future behaviour (Sniehotta, Scholz, & Schwarzer, 2005) in (Rich et al., 2015). 
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2.17 Conceptual Framework 
The main goal of the study is to assess adherence to ART and its detenninants as well as 
treatment outcomes among adolescents. The relationship between adherence, its 
determinants and treatment outcomes among adolescents is conceptualised in Figure 5. 
Generally, treatment outcomes for HIV are detennined by adherence. Adherence is 
dependent on a number offa ctors, which have been classified as individual (patient) factors, 
socio-cultural, socio demographic and health service factors (Hardon et al., 2006). At the 
individual level, factors like medication side effects, cost of care, inadequate knowledge 
might adversely affect adherence (ibid). In addition, mental related factors such as 
depression and anxiety, have been found to adversely affect adherence to ART «Reisner et 
al., 2009; Petersen et ai., 2010). Socio-cultural factors that may also affect adherence are, 
for example, beliefs of the guardian or the adolescent and patient's perception of illness. 
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PATIL" FACTORS SOCIG-CliLTh"RAL DE:\K>GRAPmC 
FACTORS 
- Side effects FACTORS 
-Internalized lligrna - Use oft raditional -Age 
-Beingbusy medicines 
- Sell 
-Oth. . iIlIIess -Bm efs in spiritual - LitfJ'acy Le\'e 
heaJjng - ReliJion 
- Not mdl!rStmding the 
rqimen 
BEALTHSERYIO: 
FACTORS TREADIE:,\"T 
- Waiting time ADBERE~CE 
m;TCOME 
- Attitude ofbealth staff TO ART 
OTBER.S FACTORS 
- Experiencing stigma 
- Pill burden 
- Running out of pills 
- Bting away from home 
Figure 5: Conceptual framework 
(Adapted from WHO, 2013) 
Adherence may also be predicted by demographic factors such as age, sex and education 
level. Health service factors such as waiting time, attitude of health workers and inadequate 
trained staff could also affect adherence. Other factors like stigma, social or familial support 
could also affect adherence (Lall et at., 2015). Some of the factors discussed above may 
even interact to affect adherence. For instance, patient's perceptions of illness could be 
affected by demographic factors as well as beliefs and preference for traditional medicines 
(Hardon et ai., 2006). Adherence for this study is the main determining factor for treatment 
outcomes. The treatment outcomes assessed in the study are retention rates, viral load 
suppression and CD4 counts. 
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2.18 Chapter summary 
Chapter two has reviewed literature on adherence generally and among adolescents. From 
the review, adherence has been shown to be generally lower among adolescents than other 
age groups. However, no study has so far reported ARV adherence rates among adolescents 
in the North West and South West regions of Cameroon. This chapter went further to review 
the determinants of adherence to ARV among adolescents. The chapter also reviewed 
literature on the perspectives of adolescents on adherence, challenges of adherence as well 
some strategies that could be used to improve upon adherence. The literature review ends 
with various methods of measuring adherence and a conceptual framework for the study. 
The next chapter discusses the methods. 
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CHAPTER THREE 
METHODS 
3.0 Introduction 
This chapter describes the methods that have been used to conduct the study. The chapter 
gives a detailed explanation of the type of study design. It also describes the study 
population and the sampling methods. It is also in this chapter that data collection methods, 
quality assurance, data processing and entry have been explained. Data analysis, study 
variables and ethical issues are all part of this chapter too. 
3.1 Type of Study/Study design 
The study employed an analytical cross-sectional study design with a record review 
component. This design was adopted because of the nature of the research objectives. While 
the cross-sectional study design addressed three of the objectives related to treatment 
adherence, such a design could not address the objective related to treatment outcomes 
(retention rates). Therefore. the treatment outcomes were measured retrospectively by 
reviewing data 011 the cohort of adolescents that were recruited into treatment between 
January 2015 and December 2015. Indeed, cross-sectional studies have been confirmed to 
be good when estimating prevalence and investigating associations between an outcome and 
risk factors (Levin, 2006), such a design is apt for the current study. Moreover, majority of 
the studies on adherence have used cross-sectional designs, and this strengthened the choice 
for this design in this current study. 
3.2 Study Location!A rea 
The study was done in Cameroon, a low-income country in Central Africa. Its territory 
covers nearly 475,650 k m2 (WHO & UN, 2015). Cameroon is boarded by Nigeria to the 
West, Chad in the North, the Central African Republic to the East and to the South by Congo 
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Gabon and Equatorial Guinea. Cameroon has 10 region with 360 districts and 14 major city 
councils with an estimated total population of 25,914,285 inhabitants as of 20 17(B U CREP, 
2019). The two official languages in Cameroon are English and French. Figure 6 shows the 
Map of Cameroon with the two study regions indicated in red. 
MAP OF CAMEROON 
SHOWING 
SOUTHWEST. NORTHWEST 
Figure 6. Map of Cameroon showing North West and South West Regions 
The population is young, with 64% being aged under 24 years. The population growth rate 
is 2.6% and life expectancy at birth was estimated at 57.3 years in 2015. Greater than 50% 
of the youthful population lives in urban areas of Cameroon (ibid). The youthful population 
is highly unemployed with an unemployment rate of 3.36% in 2018 (ILO, 2019). 
The Ministry of Public Health coordinates all health services of the country. The health 
system adheres to the African Health Development guideline based on the district health 
system. According to this system, the health system is organised into three levels: the 
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operational level, which is the district health service; the intermediate level which is the 
regional delegations of health and responsible for technical support; and the central level or 
the ministry of health which functions to oversee the both the district and regional levels as 
well providing national guidelines for health care delivery in the country. As for the health 
facilities, they are divided into several categories: the general or regional hospitals which 
are found in every region hence there are 10 general hospitals, the central hospital in 
Yaounde, district hospitals in every district, district medical centres and integrated health 
centres (WHO, 2016b). 
In Cameroon, the top leading causes of deaths as of 2018 in descending order are HIV / AIDS 
(14.2%), lower respiratory tract infections (10.5%), malaria (8.8%), neonatal infections 
(8.5%) and diarrheal diseases (5.0%) (BLICREP, 2019). As regards maternal mortality ratio, 
it is still high at 590 per 100,000 live births (WHO & UN, 2015). 
In 2016, there were 560,000 people living with HIV and 37% were on antiretroviral therapy 
in Cameroon (UNAIDS, 2019). There have been 32,000 HIV related deaths recorded since 
the year 2000, and 320,000 children have been orphaned by AIDS (WHO, 2014). The initial 
response by the Cameroonian government to the increasing trends in HIV / AIDS infection 
was the creation of a National AIDS Control Committee (NACC) to coordinate the National 
AIDS Programme in 1986. Later in 2000, the first national strategic plan was drawn for HIV 
to over the period 2000 to 2005. Another national Strategic plan to cover 2006-2010 was 
later made and implemented accordingly (Mbanya, Sarna, & Tchounwou, 2008). The 
current national plan covers 2018-2022, and the objectives are based on the 90-90-90 WHO 
targets for HIV. 
As regards the use of ARVs, the number of people receiving ARVs treatment increased from 
17,156 in 2005 to 168,249 in 2015 indicating an increase of over 10%. Although there was 
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an increase, it was not enough as it was estimated that about 560,000 people were in need 
of ARVs (WHO, 2016b). It is for this reason that the number ofHIV treatment centres was 
increased by over 100 additional treatment centres in 2017. For example, initially the South 
West region had 21 treatment centres but now has 34 and the North West that had 27 now 
has 39. There is an ongoing plan to have all health facilities providing ARVs to at least HIV 
positive pregnant women and their children by end of 2018 and this has been partly 
achieved. 
3.2.1 Location of the study Area 
Cameroon is one of the countries with the highest prevalence ofHIV in the Central African 
sub-region with a prevalence of 3.7% (PEPFAR, 2018b). It also ranks among the top 20 
countries in the world with the highest number of adolescents with HIV (UNICEF, 2015). 
In this regard, the study selected the North West (NW) and South West (SW) Regions 
(Figure 7) ofthe country as they have the one of the highest prevalence of HI V in the country 
5.1% and 3.8% respectively(PEPFAR, 2018b). These regions form the former British 
Southern Cameroon that became independent by joining the Republic of Cameroon in 1 
October 1961 (Dze-Ngwa, 2015). 
3.2.2 Climate 
Generally, the study area is situated within the humid climatic zone of tropical Africa 
characterised by two seasons, namely, the wet and dry seasons. The wet season is usually 
the longest covering at least eight months of the year and runs from Match to October while 
the dry season spans from November to February. The two regions are located within the 
Cameroon Volcanic Line (CVL) which is dominated by highlands as a result of active 
mounting building process from volcanicity. This, together with other determinants such as 
winds and the closed proximity of the area (especially the South West Region) to the 
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AtlantI,c  Ocean hvae g'Iv en th e se remons of study a unique climate often referred to as the o' • 
Cameroom,a n type 'thin the Koppen Classification System of Climates (Nkemasong. WI 
2014). 
------------------,,----1 
KEY 
Study Site 
o Region Capital 
/ Regional Boundary 
,.J" ·'own Boundary 
Figure 7: Map of the North West and South West Regions showing the Study Sites within 
the Health Districts 
Average rainfall is generally high ranging from 1700mm in places such as Nkambe to 
IO,OOOmm in Debundcha, making it the second wettest places in the world after Cherapunji 
in the foothills of the Alpine Himalayas in India, Like rainfall, temperatures are generally 
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Atlantic Ocean have given these regI.O ns f d0 stu  y a uru.q  ue climate often referred to as the 
Camerooru.a n type within the Koppen Classification System of Climates (Nkemasong, 
2014). 
-----------------,,---~ 
KEY 
Study Site 
• Regiun Capilill 
/ Regional Boundary 
~ Town Houndary 
Figure 7: Map ofthe North West and South West Regions showing the Study Sites within 
the Health Districts 
Average rainfall is generally high ranging from 1700mm in places such as Nkambe to 
IO,OOOmm in Debundcha, making it the second wettest places in the world after Cherapunji 
in the foothills of the Alpine Himalayas in India. Like rainfall, temperatures are generally 
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high throughout the year with places such as Tiko and Muyuka having mean annual 
temperatures of over 27°C while places such as Kumbo and Ndu have mean temperatures 
around l"FC (Amawa, 2009). The sustain temperatures alongside the numerous water 
bodies in these two regions make it an endemic zone for certain communicable diseases 
especially malaria, typhoid and dysentery which remain key public health concerns in the 
country. 
3.2.3 Socio-Demographic Characteristics 
According to the 2005 population and housing census whose results were released in 2010, 
the North West and South West Regions had a total population of over 3.2 million people, 
making up some 17% of the total population of Cameroon (BUCREP, 2016). This 
population was broken down into 1,804,695 and 1,384,286 inhabitants for the North West 
and South West Regions respectively. Nonetheless, given the country's population growth 
rate of 2.6% and the high fertility rate of3.9, the populations of the two regions under study 
should be well over 4,017,706 inhabitants, with slightly more than half of the population 
(52%) residing in urban centres. The populations of the regions are dominated by the 
females. 
Socially, the two regions are made up of a multiplicity of ethnic groups including the Bantu, 
Semi-Bantu and the Fulani ethnic groups. However, given a common colonial history, the 
regions' educational and legal systems are basically the inheritance of the British systems 
introduced during the colonial period, particularly after the defeat and dismissal of the 
Germans in the First World War; that is, between 1919 and 1961 when the area gained 
independence from Britain by joining the already independent Republic of Cameroon. 
Religion wise, the area is equally made of a diversity of religious belief systems with the 
dominant ones bein g Chr' t' . I IS lantty, s I am and African religions. The South West Region is 
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dominated by the Christian religion, partly because of the region's proximity to the 
Cameroonian coastline which was the point of contact of the early Christian missionaries 
that began preaching the Gospel of Christ and converting native Africans (Cameroonians) 
from African religion to Christianity. The North West Region equally has Christians; 
however, there is a very significant number of Muslim converts as a results of the region's 
closeness to Northern Cameroon and Nigeria where the spread of Islam was pervasive. 
3.2.4 Economic Activities 
The economic activities in the North West and South West Regions are dominated by 
agriculture, which employs about 80% of the active age population. The North West Region 
is characterised by the cultivation of crops and rearing of livestock especially cows, goats 
and sheep (even though the poultry and piggery livestock sub-sectors have been 
significantly developed over the past couple of years). Subsistence crop cultivation, mainly 
for home consumption, is carried out by the semi-bantu ethnic group (and largely involves 
the women), while cattle rearing is carried out mostly by the Fulanis who have a long track 
record of pastoralism and is predominantly done by the men. 
The main crops cultivated in the North West Region are mainly cereals (especially maize, 
beans, soya bean, cow pea among others), market gardening crops (involving vegetables, 
green spices, carrots and so on) given that the area enjoys a climate reminiscent of the 
temperate region, root crops and tree crops. However, a limited degree of plantation 
agriculture is equally carried out in the area, and this is typical of tea cultivation in Ndu and 
Ndawara. This is done along other cash crops like Arabica and Robusta coffee. 
Agriculture in the South West Region is, however, dominated by plantation activities carried 
out by agro-industrial complexes such as the Cameroon Development Corporation, 
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PAMOL. DELMONTE as well as small holders. The main plantation crops cultivated 
include palms, banana, rubber and tea among others. There are also farmstead and small-
holder plantation schemes involved in coffee and cocoa cultivation as well. Given the 
dominance of plantation activities in this region. there has been a long-standing record of 
geographical labour mobility from different parts of Cameroon especially from the North 
West Region in search of work in these plantations. This mobility has made many towns in 
the South West Region to be cosmopolitan as they are composed of people from different 
ethnic and tribal origins. This has also added to the spread of the HIV epidemic in the region. 
Indeed, given the appalling social conditions which characterise these plantations, there has 
been high levels of promiscuity and juvenile delinquency, which have all pre-disposed the 
popUlation to sexually transmitted diseases such as HIV and AIDS. It is in this connection 
that one of the HIV treatment centres considered in this study is in the Tiko Health District 
in Tiko Town that grew up largely as a result of palm and banana plantations of the 
Cameroon Development Corporation. The town is noted for hosting one of the corporation 
camps of the plantation workers. 
Away from agriculture, the service sector has equally employed about 20% of the active 
popUlation. This is dominated by the commercial and transportation sectors. There exists a 
diversity of commercial activities given the growing urbanisation process (estimated at 
52%) in the region (BUCREP, 2010). 
3.2.5 Healthcare Services and Infrastructure 
The North West and South West Regions host a number of health facilities which range 
from public to private and faith-based health facilities. Each of these regions has a regional 
hospital in its regional capital. They also have a district hospital in each of the districts 
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within the region, hence the North West region has 7 district hospitals and the South West 
has six district hospitals. 
The regional hospitals act as referral centres for all other health facilities within the region. 
The North West region hosts two of the most renowned faith-based hospitals in Cameroon, 
namely St. Elizabeth General Hospital and Cardiac Centre, owned by the Catholic Church 
as well as the Banso Baptist Hospital, which is owned by the Cameroon Baptist Convention. 
As of2018, the South West Region had 34 HIV operational treatment centres and the North 
West Region had 39. Most of these centres have at least an adolescent being followed up in 
care. Five and four health facilities, respectively, were purposively selected from the South 
West and North West regions for this study. These facilities are briefly described below. 
3.2.7 Description of Selected Health Facilities 
The section of the methods chapter presents a brief description of the selected health 
facilities; 
1. The Regional Hospital Buea: This is the general hospital of the South West region. It 
serves as the regional referral point to all other health facilities. It has the necessary 
specialties and serves a target population of 99,286 inhabitants. The hospital is made 
up of a number of units/departments/centers including the following: the medical unit 
(male and female), the surgical unit, the paediatrics unit, the maternity unit, the 
HIV/AIDS unit, the Laboratory unit, the X-ray unit, the hemodialysis center, the 
Tuberculosis center, the theater and the Diabetes center among others. The Buea 
Regional Hospital (BRH) serves clients from all over Buea and its environs. These 
clients either come to the hospital for consultation and treatment or they are referred 
from other health centers and clinics around. This hospital has a total of 45 HIV positive 
adolescents registered on treatment. 
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" The Regional Hospital Annex Limbe: This is another major hospital in the South West 
Region and seconds the main regional hospital as an annex. It serves a target population 
of 27,814 inhabitants and receives clients from all over Limbe, neighbouring towns and 
villages. This health facility has the highest number of adolescents on ARV treatment 
(351) in the South West Region as of2017. Apart from the HIV/AIDS unit, the health 
facility has other departments: the medical unit, the surgical unit, the paediatric unit, 
the maternity unit, the laboratory unit, the X-ray unit, the Tuberculosis center, the theater 
department and the Out-patient department. 
3. District Hospital Kumba: This is one of the largest district hospitals in the South West 
region, which offers consultation, maternity, paediatric, HIV/AIDs care to inhabitants 
of Kumba and its neighbours. The facility receives over 1000 patients on monthly basis 
but this has significantly reduced since the Anglophone crisis started. This hospital was 
recently burnt in February 2019 as a result of the political crisis in the country. It is 
currently undergoing renovations. At the time data was collected, it had 85 adolescents 
registered on treatment. 
4. The Tiko District Hospital: This is another district hospital in the South West Region. 
It serves a target population of 5706, and offers consultation, maternity care, laboratory 
HIV/AlDS services and family planning. It had 20 registered HIV positive adolescents 
on treatment at the time of this study. 
5. The Baptist Hospital Mutengene: This is one of the largest faith-based hospitals in the 
South West Region. The Baptist Hospital Mutengene (BHM) offers medical, spiritual 
and psychosocial care, seeing at least 5,000 patients per month with different health 
problems from various towns in the South West and the Littoral Regions. The hospital 
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coordinates a number of HIV programmes in the region. As of 2018, it had 201 HIV 
positive adolescents registered on treatment. 
6. The Regional Hospital Bamenda: This is the main regional hospital in the North West 
region and serves the population of Bame nd a and neighbouring villages. It is the referral 
hospital for all other hospitals in the region. It serves a target population of 41,162. It 
offers a variety of health services; medical, paediatric, HIV / AIDS, surgical, 
ophthalmology, dentistry, tuberculosis care, and haemodialysis. It had 78 adolescents 
registered on treatment in 2018. 
7. The Banso Baptist Hospital: This is another faith-based hospital in the North West 
Region. The Banso Baptist Hospital is a full service hospital with a wide package of 
activities. It offers health care to an estimate 250-300 patients on a daily basis. 
Outpatient services include the entire range of family medicine, including prenatal care 
and childcare. It receives on average 4,000 outpatients on monthly basis with 80-100 
deliveries. The Banso Baptist Hospital host a strong HIV programme that has the 
support of the Cameroon government and the United States government. This HIV 
program intervenes in community education on HIV and AIDS prevention and 
treatment, prevention of mother to child transmission ofHIV (PMTCT), prevention and 
treatment of comorbidities such as tuberculosis (TB), provision of ARV, orphan care, 
HIV support groups and palliative care for HIV positive persons. However, due to the 
crisis in Cameroon, the level of activities in this health facility has been greatly reduced. 
It had 45 adolescents registered on treatment at the time of data collection. 
8. The St Elizabeth Hospital and Cardiac Centre Shisong: It is one of the largest faith-
based hospitals in the North West region. It also hosts the largest cardiac centre in 
Cameroon that attracts patients from all over Cameroon and some neighbouring 
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countries. It serves a target population of 17,331 inhabitants. Its activities range from 
consultation. paediatric, surgery, dentistry, ophthalmology, to HIV care. It had 73 
adolescents registered on treatment. Like the Banso Baptist hospital, its functionality 
has been significantly reduced as a result of the ongoing crisis in the country. 
9. The Nkwen Baptist Hospital: This hospital is of the Baptist faith. It is also in the North 
West region. It serves a population of23,289 inhabitants and offers out-patient services, 
maternity care, HIV/AIDS care, ophthalmologic and dental services. It offers care to 
patients in Bamenda town and its environs. As of 2017, it had 92 HIV positive 
adolescents registered on treatment. 
3.3 Study Population 
This study enrolled adolescents (lO-19years) who were living with HIV and aware of their 
status. For the cross-sectional component of the study, respondents from among adolescents 
who were already enrolled in treatment centres and had been on treatment for at least 6 
months were recruited. Their records were reviewed from the time of ART initiation up to 
the time of data collection. 
For the records review design, the hospital files of adolescents who were initiated in 
treatment between January 2015 and December 2015 were assessed to obtain data on their 
retention rates. 
3.4 Inclusion and Exclusion criteria 
3.4.1 Inclusion Criteria 
The inclusion criteria of adolescents were as follows: 
- the adolescent had to be registered on treatment. 
-he/she should have been on treatment for at least 6 months. 
-if less than 18years, should have a legal guardian. 
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3.4.2 Exclusion Criteria 
Adolescents who were critically ill were excluded from the study. Adolescents who were 
not aware of their HV status were also excluded. 
3.5 Sampling 
3.5.1 Sample Size determination 
The sample size of the study is 460. This was estimated using the Cochrane's formula for 
calculating sample size for cross-sectional studies as follows: 
Z 2p(1-P) 
n= d 2 
Where; 
n= minimum sample size required for the study 
Z2= critical value, 1.96 
p= expected level of adherence (36%) 
d=precision, which was set at 0.05 
The expected level of adherence (self-report) (36%) used was obtained from a 2017 study 
in Cameroon that measured adherence among adolescents (Fokam et al., 2017). Based on 
the assumptions above, the minimum sample size estimated was 354. A non-response rate 
of 30010 was assumed so as to increase the power of the study, and this gave a total sample 
size of 460. In this regard, 460 adolescents were planned for the study between August 2018 
and January 2019. Out of this number, 455 questionnaires were retained giving a response 
rateof99%. 
3.6 Sampling 
A multistage sampling procedure was followed in this study to select respondents. The 
process and procedures are described below in detail. 
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3.6.1 Sampling of Health Facilities 
A list of health facilities that had HIV treatment centres was obtained from the South West 
and North West Regional Delegations of Health. As noted earlier, there were 34 treatment 
centres in the South west region and 39 in the North West. From this list, 9 health facilities 
were purposively selected based on the number of adolescents registered on treatment. That 
is, the treatment centres with the highest number of adolescents on treatment were selected. 
Table 2 shows the estimated number of adolescents on treatment in each of the selected 
facility as of December 2017 based on data obtained from the HIV Regional Technical 
Group (RTG) for the North and South West Region. Probability proportionate to size sample 
allocation was used to obtain the number of adolescents per site (Table 2). 
Table 2 Number of Adolescents on treatment in the selected Health Facilities 
Health Facility (HF) Total Number Number Sampled 
South West Region (SW) 
Regional Hospital Limbe 351 163 
Baptist Hospital Mutengene 201 93 
District Hospital Kumba 85 41 
Regional Hospital Buea 45 21 
District Hospital Tiko 20 9 
Total for SW 702 327 
North West Region 
Regional Hospital Bamenda 78 32 
Banso Baptist Hospital 45 19 
St Elizabeth Hospital Kumbo 73 30 
Nkwen Baptist Hospital 92 52 
Bamenda 
Total forNW 228 133 
Grand total 990 460 
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3.6.2 Sampling of Participants 
For the cross-sectional component of the study, participants were selected using systematic 
random sampling. For example, if a treatment centre had 63 registered adolescents and 30 
participants had to be selected for the study, the 63 was divided by 30 to get the sampling 
interval which in this case will be 2. The list was numbered starting at 1 and then a random 
start was selected from say 1. Using the interval of2, participant 3 then 5, 7 and so on were 
selected until the 30th participant was selected. All the selected participants were then 
approached on their various clinic days to participate in the study. Participation in the study 
was voluntary. Some of the participants refused to be part of the study. The main reason for 
refusal was lack of time to answer the questions. Those who could not participate were not 
replaced as the sample size estimation had accounted for non-response. 
As for the records review, data on all the adolescents who started treatment between January 
2015 and December 2015 were used. This gave a total of257 adolescents on ART. The year 
2015 was selected because retention rates were to be measured at 6, 12 and 24 months. 
Therefore. two years from 2015 was 2017 which was within the time to obtain 24 months 
data for the study given that data for this study was collected in 2018. 
3.7 Data Collection Methods and Tools 
3.7.1 Data collection methods 
Quantitative data were collected using questionnaires that were administered to the 
participants individually. Part of the quantitative data were also obtained by using the data 
extraction fonn. To calculate retention rates, counting and sorting was done on the registers 
to obtain data on lost to follow up and deaths for the selected cohort of adolescents. Transfer 
out cases were not included in the calculation for retention rates. 
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3.7.2 Data Collection tools 
1. Questionnaire 
Questionnaires were used to collect data for the study (see appendix 8). The questionnaire 
was divided into 9 sections as follows. 
Section 1: This section had questions on the demographic characteristics of the participants, 
including age, sex, educational level, occupation, religion, place of residence, living alone 
or with parent/guardian, means of travel to hospital and distance health facility. The 
demographic questions were developed by the researcher based on reviewed literature of 
the possible demographic determinants of adherence. 
Section 2: This part focused on report to hospital. Participants answered questions on the 
frequency of hospital visits and reasons why they may skip hospital appointments. They 
were given a litany of reasons to choose to explain why they missed hospital appointments. 
Some of the options were transportation problems, financial constraints, being in school or 
out of town and forgetting among others. Participants could choose more than one reason. 
Questions from this section were adopted from the AIDS Clinical Trial Group (ACT G) 
adherence follow-up form. 
Section 3: This section asked questions on participants' knowledge about drugs as well as 
adherence levels. Participants were asked if they knew the name of the drug they were 
taking. If the answer was yes, then they went further to give the name of the drug. They 
were also asked the daily dosing frequency and the number of pills per day. Participants 
were also asked if they missed pills in the last 30 days and the number of pills missed. They 
were further asked on how often they felt difficulties taking their medications on time. 
Questions for this section were adapted from the CASE (Centre for Adherence Support 
Evaluation) Adherence Index tool. Questions from this tool were adopted because the 
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questions are simple and could easily be understood by the participants since they were quite 
young. The CASE adherence index is also a standardised tool which is widely used in self-
report measurement of adherence. 
Section 4: This section was meant to evaluate medication interruptions. Participants were 
asked to give reasons why they missed medications. Some of the reasons were forgetfulness, 
avoiding side effects, lost pills, being away from home and religious belief in spiritual 
healing, to name a few. The questions from this section were adapted from the ACTG 
adherence form as they are standard and were well suited for the context of the study. 
Section 5: The fifth section of the questionnaire aimed at probing into reasons for taking 
medications. The participants were given a wide range of options to select from. Some of 
the reasons were: taking ARV drugs makes me healthy and taking medications to stay 
healthy for the family. These were also adapted from the ACTG adherence questionnaire. 
Section 6: Support from healthcare providers was assessed in this section of the 
questionnaire. Participants responded to questions about being worried or doubting 
information they get from hospital staff. They were also asked if they worry about staff not 
keeping their information private. Some of these questions were adapted from the ACTG 
questionnaires while others were derived from literature. 
Section 7: Section 7 was about cost of medications and method of payment. Participants 
were asked if they pay for drugs. They were also asked the cost of the drug and who paid 
the cost of the drug for them. Questions from this section were not adapted. They were 
developed based on the underlying idea of assessing if participants pay for drugs. 
Section 8: This part of the questionnaire was to evaluate participants for internalised stigma. 
There were six questions, which the respondents were to respond dichotomously _ agree or 
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disagree. Some of these were about feeling guilty, dirty, worthless or ashamed of the 
positive HIV status. These questions were adapted from the Kalichman scale, which has 
been standardised for use in research. 
Section 9: This is the last part of the questionnaire. It sought participant's opinion on 
improving adherence. Participants had to respond dichotomously- yes/no to the options for 
improving adherence which included reducing pills, sending reminder messages and if 
medications should be brought home. The participants were also given the chance to write 
other suggestions which could improve adherence. The questions from this section were 
developed from reviewed literature. The final questionnaire for this study is shown in 
Appendix 8. 
2. Data Extraction form 
In order to determine the treatment outcomes, a data extraction tool was designed and used. 
The first section of the form was to obtain clinical information about the patient and some 
of these were age at first clinic visit, date of ART initiation, if the patient was a transfer case, 
name of current treatment, if patient had stopped first line treatment and was on second line 
treatment. The age and sex of the participant were also entered so as to validate the 
information on age and sex on the questionnaire. 
The second part of the form was aimed at obtaining information on the patient's previous 
visits. The dates of the last 10 previous visits were taken. CD4 count information was on 
the third part of the questionnaire. The last 10 CD4 counts were taken with the dates in 
which they were carried out. The fourth section was for viral load results and just like for 
CD4 counts, the 10 most recent results were used. The last part of the form was on the ARV 
refill dates. The last 12 refill dates were obtained starting with the most recent ones. 
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In summary, each participant was administered one questionnaire and one data extraction 
form. The questionnaire was interviewer-administered to the participants. The data 
extraction forms were filled by the research assistant using hospital records. A copy of the 
data extraction form is shown in Appendix 9. 
3. Facility Preparedness checklist 
To assess facility preparedness towards care of adolescents, the John Snow Inc (JSI) tool 
for assessing readiness of facilities towards HIV care was used. The tool is composed of 6 
main domains: leadership, management of ARVs, programme protocols, experience and 
staffing, laboratory capacity as well as drug management and procurement. Each domain 
was scored on a total of 5. 
Leadership: The domain of leadership had two indicators: the facility's leader and model 
of care. The first indicator was aimed at evaluating if the health facility had a leader who 
manages the HIV programme and has experience and/or training in managing ARV 
programmes. If the facility had no identified leader it was given a score of 1. If the facility 
had some level of leadership at the level of the facility and the community it was scored 2. 
The facility was scored 3 if it had a leader with vision and some experience managing 
healthcare-related interventions, but needed help to start designing and setting up program 
and protocols. Ifthe facility had a leader with vision and experience managing HIV related 
healthcare programs who is engaged in establishing an Anti-retroviral program it was scored 
4 and scored 5 if there was a leader with experience in the management of the ARV program. 
The second aspect of leadership was the model of care - the availability of a detailed model 
of care with operating procedures that have been standardised. A facility which had not 
identified any possible model of care for the ART program was given a score of I. The 
facility could have some models of care which could be adapted to ART but needed 
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assistance. In that case. the facility obtained a score of 2. A health facility was scored 3 if it 
had a model of care but which was not detailed. A score of 4 was obtained by a facility that 
had a detailed model of care but with operating procedures still being prepared. If the model 
of care was detailed, fonnalized and approved the facility had a score of 5. The total score 
for each of the components was calculated and then the average score obtained to have a 
total score leadership score on 5. 
,\[anagement of ARVs: The management of ARVs had four different components-
availability of staff for ART, availabil ity of comprehensive services, availability of physical 
space and the level of community partnership. Each of these components was scored similar 
to leadership. For ART services, a facility was scored 1 if it had few or no staff in HIV 
outpatient care or if the staff had not received any training or were inexperience. If the 
facility had enough staff for HIV care but who were not trained or were inexperienced, it 
was scored 2. A score of 3 was given to a facility that had staff with some level of training 
but still inadequate. A facility with staff who had limited experience and might require some 
training was scored 4. The highest score of 5 was given to a facility that had staff 
experienced and trained in all areas of HIV care. 
In the case of comprehensive services, a facility was scored 1 if the HIV care on site or 
through linkages was not enough. However, if the facility had access to voluntary 
counselling and testing on site through referral cases, provides HIV care on site but lacks 
adequate capacity for expansion without assistance, it was scored 2. A facility obtained a 
Score 00 if it had some HIV services on site and provides treatment for sexually transmitted 
diseases as well as voluntary counselling and testing. A facility that could provide 
prevention from mother to child services, more extensive out-patient services for example 
treatment for tuberculosis but still had gaps in some support services and linkages it was 
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given a score of 4. A facility scored 5 if it had the following aspects, VeT on site and 
essential support services like counselling, monitoring and adherence support programmes 
as well as nutrition counselling. Additionally, the facility was supposed to have a full 
package of services for the treatment of tuberculosis, sexually transmitted infections and 
other HlV related opportunistic infections. 
In terms of physical space, if the facility had no defined or confidential space for HIV 
positive adolescents it was scored 1. A facility that had limited space for the adolescents but 
with lack of confidentiality obtained a score of2. A facility scored 3 if it had no designated 
space but with temporal space available as well ongoing plans for a section for adolescents. 
A score of 4 was obtained if the facility had some space for adolescents which ensured 
confidentiality but was not enough or limited. A facility with adequate space that ensured 
the confidentiality of the HIV positive adolescents obtained a score of 5. 
The last aspect of ARV management was community involvement. A facility scored one if 
it had no community network or support established. If the facility had started some 
community mobilisation for support and made arrangements to involve adolescents living 
with HIV, it was scored 2. A health facility that had made contacts with community leaders 
and also had some inputs from people living with HIV in such communities obtained a score 
of 3. Facilities that had already established a network with stakeholders in health, 
community activists, faith based and non-governmental organisations and performed 
community needs evaluation had a score of 4. If there was already an existing formal 
community collaboration with the full involvement of people living with HIV, traditional 
healers, faith based and non-governmental organisations among others, the facility was 
score 5. 
The total score for this section was then obtained and the average score calculated to get the 
total domain score on 5. 
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Program Protocols, Management and Evaluation: This indicator had three components: 
ART guidelines, management information systems (MIS), programme monitoring and 
evaluation. The availability of program protocol was the first indicator on this domain. If a 
facility had some care protocols but did not have access to the national protocol or guidelines 
for HIV treatment, it was scored. A facility that had some experience with HIV related 
guidelines but with no experience on monitoring and evaluation was scored 2. A facility 
obtained a score of 3 if it had the protocol but not being used or approved by the program 
management. A score of 5 was obtained if the facility had approved national guideines for 
HIV screening, eligibility criteria, ARV initiation, clinical and laboratory monitoring and 
follow-up, management of side effects and treatment failure. 
Secondly, the management information system was also verified. Facilities with very basic 
records and no management and information system to track patients was scored 1. If a 
health facility had a basic management and information system to track patients but with no 
specific HIV information included, it was scored 2. A facility got a score of 3 if it had some 
elements of the management and information system but with inadequate capacity for 
expansion to meet up with the needs of the ARV program as well as needing improvement 
in medical record keeping. Facilities that had a system of follow-up but with gaps in tracking 
of patients and charting was scored 4. A score of 5 was obtained if the facility had a system 
in place for tracking patients, medical records, charting for clinical care and laboratory 
results with well-defined flow sheets for ART. A total program protocol score was obtained 
and the mean score calculated to get the domain score on 5. 
Program monitoring and evaluation was also assessed. A facility that had no procedures for 
program level monitoring and evaluation was scored 1. If the facility has some procedures 
or plans for program monitoring and evaluation which were insufficient for the site, it was 
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scored 2. A facility scored 3 if it had some related monitoring and evaluation with some 
training in monitoring and evaluation but with no specific procedures for ART monitoring 
and evaluation put in place. A score of 4 was for a facility that, had some plans and 
procedures for program level monitoring and evaluation and quality improvement for ART 
but requiring some upgrading. If a facility had a well-established program monitoring and 
evaluation plan, with process and outcome measures of ARV program with results used for 
program decision making it was scored 5. 
Experience and staffing: This is aimed at assessing the facility capacity in terms of human 
resources. This domain had two components; staff experience and management, training 
and retention. 
For staff experience, a facility obtained a score of I if the available staff had limited 
experience in HIV care with no training as well as no plans in place for staff training or 
recruitment. If the facility had staff with HIV care experience but with limited ART training 
and no resources for immediate addition of staff, but with plans to recruit it was scored 2. A 
facility obtained a score of 3 if they had staff with HIV care experience but with limited 
training. If a facility had a staff with knowledge and experience in ART with minimum 
training for prescribing, follow-up and adherence support and counselling it was scored 4. 
A facility with adequately trained staff that have experience in primary HIV care and ART 
including drug prescription, follow-up adherence counselling and support was scored 5. 
Management, training and retention was one the indicators in this domain. A facility that 
had no plans for training of staff or evaluation of staffing needs was scored 1. A facility that 
had started developing a plan for staffing but required additional plans with resources for 
recruiting more staff, training and management obtained a score of 2. If a facility had a 
staffing plan but with no official procedure for hiring more staff and training, it was scored 
3. A facility scored 4 if it had staffing plans put in place and functional but required more 
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additional recruitment and training. The total score was also obtained based on the stage of 
the facility and the average score per facility calculated on a scale of 5. 
Laboratory capacity: It had two components aimed at assessing the facility's testing ability 
and quality standards. For the testing ability, a facility scored 1 if it had limited or no 
laboratory test for HIV persons as required by WHO or the national protocol and with no 
quality assurance mechanism. A score of 2 was obtained if the facility had access to the 
required national or WHO protocols but which are not reliable. If a facility had access to the 
protocol for screening and monitoring as required by WHO or national protocols, it obtained 
a score of 3. A health facility with a high laboratory capacity to perform exams such as liver 
function tests, full blood counts, and kidney function tests, screening and monitoring as per 
the protocol but not able to run CD4 counts and viral load tests had a score of 4. A score of 
5 was for a facility with the full package of tests required by the guidelines including tests 
for viral load suppression and CD4 count and with constant availability. 
In the case of quality standards, a facility with no quality standards and no program for 
equipment maintenance and limited availability of laboratory supplies scored 1. If the 
facility had poor quality laboratory standards, unreliable maintenance of equipment with a 
poor quality assurance process in place, it was scored 2. If there was some minimum level 
of reliable equipment with functional maintenance program and laboratory supply available 
and the laboratory has some quality standards with irregular compliance it was scored 3. A 
facility with reliable equipment and a backup plan with a maintenance program in place, 
performs internal and external quality assessments but with some occasional breaks in 
service, it was scored 4. The maximum score of 5 was obtained if a facility had internal and 
external quality assistance, with a maintenance program, reliable equipment and constant 
availability of reagents and other laboratory supplies. The total laboratory capacity score 
was also obtained, and the average calculated to get a score on 5 for laboratory capacity. 
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Drug management and procurement: This is the last section of the tool and it had three 
components; supply chain, pharmacy management and financial resources for AR V and 
other drug procurement. 
For the supply chain, a facility with a limited supply chain in place requiring improvement 
in major areas including ARVs as well as creating a quality assurance for service availability 
was scored 1. If there was some reliable supply chain that needed improvement in few areas 
with adaptations to accommodate some requirements for ARVS and limited quality 
assurance for product availability, it had a score of 2. A facility scored 3 if it had a supply 
chain in place but needed adaptations for some specific ARV requirements and quality 
assurance process for product availability was not available. A score of 4 was obtained by a 
facility that had a secure supply chain but with some needs of technical assistance in 
inventory management and limited quality assessment for product availability. A facility 
that had a secure supply chain from supplier to the facility with all the required storage 
conditions, a quality assurance system with a monitoring system in place for AR V s to 
prevent any stock outs was scored 5. 
The second component of this domain was pharmacy management. A health facility with 
no established procedures for ARV s, no follow up inventory management procedures for all 
the essential drugs was scored 1. A facility that had no inventory procedures for ARVs but 
with limited, unreliable inventory management procedures for other essential drugs was 
scored 2. A score of 3 was obtained by a health facility that had no inventory management 
for ARVs but with clearly implemented inventory management procedures for other 
essential drugs. Health facilities that had started the process of having an inventory 
management procedure for ARVs but which was not yet completed as well as having a 
developed inventory management process for essential drugs had a score of 4. To obtain a 
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score of 5. the facility should have developed and put in place an inventory management 
tool and procedure for ARVs which should include forecasting, making calculations for 
regular stock reports, dispensing and making orders for emergency supplies. The facility 
was also supposed to have an established inventory management process for other essential 
drugs. 
The last section of this domain was to assess financial resources for ARVs and other drug 
procurement. If a health facility had not identified sources for ARVs, had very limited 
resources for drug procurement, management of ARV side effects and other complications, 
with no identified sources for essential drugs, it was scored 1. A facility that had identified 
limited sources for ARVs, but with limited resources for drug procurement, management of 
ARV side effects and other complications, with no identified sources for essential drugs was 
scored 2. 
If the facility had identified potential sources of funding for the ARV  s drugs but yet to 
complete the arrangements, required more funding to ascertain the availability of other 
essential drugs, manage medication related side effects and other HIV related opportunistic 
infections, it had a score of 3. A health facility with a short-term funding for procurement 
of ARVs with no certain long term assurance of funding, however had adequate supplies of 
essential drugs, drugs for the management of ARV related side effects and other 
complications, obtained a score of 4. To get a score of 5, the facility was supposed to have 
a secured source or sources for AR V s for the short term with a plan for commitment and 
drug supply for patients for at least one year and follow-up funding. In addition, the facility 
was supposed to also have adequate supplies of essential drugs, drugs for the management 
of ARV related side effects and other complications. 
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The total score for this domain was obtained and the mean scored calculated to have the 
score for drug management and procurement on a 5. 
The total score for each facility was then calculated on a total of 30. A facility with a score 
less than 8 is classified as being at stage 1, which implies the facility is at the stage of 
mobilizing for the programme. A stage 2 facility scored 9-13 score and is the stage of service 
delivery planning while a stage 3 facility scoredl4-18 and is therefore preparing to begin. 
Stage 4 is the action stage and is for facilities with a score of 19-24. The final stage is stage 
5 and is meant for facilities with a score of 25-30. At this stage, the facility needs support, 
maintenance and expansion. Table 3 presents a summary of the interpretations for facility 
score. 
Table 3: Scoring Summary of the JSI Tool 
Scoring Stage Meaning 
1-8 Program mobilization 
9-13 2 Service Delivery and planning 
14-18 3 Preparation 
19-24 4 Action 
25-30 5 Support, Maintenance and expansion 
3.8 Quality Control/Assurance 
3.8.1 Training of research assistants 
Two field assistants were recruited to assist in data collection. The two field assistants had 
bachelor's degree in nursing. The field staff were invited to a two-day workshop where the 
principal investigator trained them. Firstly, they were made to understand the objectives of 
the study. They were then given definition of key concepts like adolescents, adherence and 
treatment outcomes. Secondly, they were trained on sampling of participants at the health 
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facility level. The assistants were further taught on questionnaire administration and data 
collection from hospital records. They also received training on ethical issues pertaining to 
the research, how to approach a respondent, obtain consent and how to administer the 
questionnaire. The assistants were also given lessons on the importance of keeping research 
information confidential. The training was done before the study commenced. The 
assessment offacility preparedness for ART care was done by the principal investigator. 
3.8 2 Pre-testing of questionnaire 
The questionnaire was pre-tested at the Buea Road District hospital in the South West region 
which was not one of the study sites. Five questionnaires were used for pretesting and the 
feedback from the testing showed a need to adjust aspects of the questionnaire to aid 
understanding and have a logical flow. This was done before final data collection. 
To determine the quality of data, some data extraction forms were randomly selected by the 
principal investigator and cross-checked with original hospital records to be sure of the data. 
All the questionnaires were verified for correct coding and completeness before processing. 
3.9 Data entry and processing 
The collected data were then entered into excel and saved in a file on a laptop only accessible 
to the researcher. As back up, the data were also saved in a drop box, so it could be retrieved 
in case of any losses. The questionnaires after entry were filed and kept in a safe cupboard. 
3.10 Variables and measurement 
Both dependent and independent variables were defined and measured. The dependent 
variables were two: adherence and treatment outcome. These variables were operationally 
defined and measured as follows: 
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3.10.1 Adherence 
For the purpose of this study, adherence was defined as the patient's ability to take 
medications as per the prescription. It was determined through self-report oflast missed pills 
or doses within the last one month. Self-report adherence was measured based on the 30 
days recall. It was calculated as the proportion of pills taken to the number prescribed within 
30 days. For example, a patient on one pill daily could have missed 2 pills in the past 30 
days, hence the adherence of that participant will be 28/30 = 93%. Based on this premise, 
participants with a self-report score of2:95% were considered adherent. 
Adherence was also measured through pharmacy records. This calculation from pharmacy 
records was done based on the Medication Possession ratio (MPR). MPR was calculated as 
the sum of the days of treatment supplied for all ART prescriptions filled, within the refill 
interval divided by the number of days during that same time period. A patient was 
considered as adherent if the MPR was at least 95%. Adherence was coded as a binary 
outcome variable. The self-report measure has been adopted for use in this study because it 
is flexible. easy to use and applicable in many contexts and age groups. As for the 
Medication Possession Ratio, which is from pharmacy refill records, it has also been used 
to measure adherence as it eliminates the problem of recall bias. 
3.10.2 Treatment outcomes 
The treatment outcomes considered for this study were viral load suppression, retention and 
CD4 counts 
Viral load suppression was considered as having the most recent viral load 
suppression results of less than 1000 copies per mI. The most recent viral load had 
to be within the past 6 months. Participants with less than 1000 copieslml were 
considered having suppressed their viral loads. This viral load was extracted from 
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patient's records in the health facility. All the viral load results done were obtained 
with the dates on which they were done. 
The retention rate was determined as the proportion of adolescents who remained on 
treatment after 6, 12 and 24 months since treatment initiation. The ART retention 
denominator was the number of adolescents on ART excluding the number who 
transferred out at 6, 12, and 24 months. 
• CD4 counts were extracted from patient's records. The results of the 10 most recent 
CD4 count tests done were taken. The cut off 200cells/ul was used to group the 
participants. Adolescents with counts greater than or equal to 200cells/ul were 
graded as having high CD4 counts. 
fhe independent variables were defined as potential determinants of adherence, and were 
grouped into patient factors, health facility factors, socio-cultural and other factors. These 
factors have been operationally defined as follows. 
3.1 0.3 Patient factors 
These are factors relating to the individual (adolescent) that might affect adherence. These 
include medicine related side effects and cost of care. These factors were coded as binary 
variables 
• Knowledge was defined as the patient's understanding of the need to take ARV 
drugs consistently. The participant answered yes/no to taking drugs to stay healthy. 
• Medicine related side effects were self-reported from questionnaires. The 
questionnaire had a question on whether side effects are one of the reasons for 
missing medications. It was coded as binary as the participant answered yes/no. 
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Cost of care was also a binary variable and the questionnaire was used to determine 
if cost of medications was the reason for missing medications. It was dichotomously 
coded as yes/no. 
Internalized stigma: Internalized stigma is that which comes from within an 
individual and shows how an individual feel, including feeling worthless, guilty or 
ashamed due to their HIV status (Kalichman et af., 2009). There were six questions 
on the questionnaire to assess internalized stigma. These questions were adapted 
from the Kalichman scale of measuring internalised stigma in HIV patients which is 
standardised and has been validated. An adolescent who agreed to at least three of 
these questions was experiencing some form of internalised stigma 
3.10.4 Health Service factors 
Health service factors are the determining variables that relate to the health facility activities 
and staff. They included waiting time and having experienced poor attitude of staff. The 
questions were all binary and patients answered as yes/no. 
3.10.5 Socio-cultural factors 
These included the use of traditional medicines, beliefs in spiritual healing and the belied 
that there were no longer in need of drugs. All the socio-cultural characteristics were coded 
yes/no and the participants answered yes if they had experienced a particular socio-cultural 
factor. 
3.1 0.6 Demographic factors 
Demographic variables in the context of this study included age, sex, educational level, 
residence, distance to health facility and living with parent or legal guardian. All these data 
were obtained from the questionnaire. The exact age was gotten and treated as a continuous 
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variable. Adolescents were also categorised based on their ages as young, middle and late 
adolescents in some analysis in other to make some specific inferences. Sex was used as a 
categorical binary variable. The level of education was divided in four categories: primary, 
secondary, tertiary and no fonnal education. Adolescents were further characterised 
according to whom they lived with, parent/guardian or living alone. As for distance to health 
facility it had four options: less than 30 minutes, 30 minutes, and 30 minutes to one hour 
and above one hour using commercial transportation or walking to a facility. 
3.10.7 Other factors 
These included variables like stigma, frequency of medications, being away from home and 
running out of pills. Stigma in this case was extemalised or stigma that is from other sources 
like family, school, media and hospital among others. It was a binary variable coded yes/no. 
The frequency of medication was measured as the number of times pills were taken per day. 
As for being away from home, participants answered yes/no if that detennined their ability 
to take medications. Running out of pills was also a binary variable with the option of 
yes/no. 
3.10.8 Statistical Methods 
The data were analysed using univariate, bivariate and multivariate statistical analysis 
methods. Univariate analysis was used to derive proportions of adherence and quantify 
adherence levels. It was also used to characterize the socio-demographic and other 
characteristics of the respondents. Bivariate analysis (using chi square tests and Fishers 
exact tests) was used to assess association between independent variables and adherence. 
For multivariate analysis, all the variables that significantly predicted adherence at the 
bivariate analysis were used. This was to obtain a parsimonious model controlling for 
confounding and effect measure modification. Adjusted odd ratios were reported and a p_ 
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value less than 0.05 was considered statistically significant at a 95% confidence level. All 
the quantitative analysis was done using STATA 15. The kappa statistics of inter-rate 
agreement was used to ascertain the difference between adherence as measured by self-
report and MPR. The scale is interpreted as follows (Table 4): 
Table 4: The Kappa benchmark scale 
Agreement level Interpretation 
0.00 Poor agreement 
0.0-0.20 Slight agreement 
0.21-0.40 Fair agreement 
0.41-0.60 Moderate agreement 
0.61-0.80 Substantial agreement 
0.81-1.00 Almost perfect agreement 
Source: (Klein, 2017) 
3.1 J Ethical ConsiderationslIssues 
This study followed the ethical requirements. The procedures to ensure ethical 
considerations are discussed in the following sub-sections of the chapter. 
3.11.1 Administrative and Ethical Approval 
To conduct the study, administrative and ethical approval were sought. Administrative 
approval was obtained from the Regional Delegation of health at the North and South West 
Regions of Cameroon where the study was carried out. Letters of approval are attached in 
appendix 11 and 12 for the North West and South West regions respectively. Approval was 
also taken from health facility authorities before commencing the study. Ethical approval 
was received from the Cameroon Baptist Convention (CBC) ethical review board. The 
approval letter is attached in Appendix 13. 
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3.11.2 Informed consent 
Before each potential study participant was interviewed, a written informed consent was 
obtained. Informed consent was obtained from adolescents who were 18 years and above 
and from the guardians of adolescents who were less than 18years. The informed consent 
ionn contained names and telephone numbers of the Principal Investigator and the contact 
email of the secretary of the Cameroon Baptist Convention Health Service Ethical 
Committee. Prior to aU interviews, the interviewers reviewed the informed consent form 
with the participant/guardian. Participants/guardian were to sign the informed consent form 
before answering the questionnaire. Participants/guardians were informed of the rational of 
the study, the procedures and length of the quantitative interviews. Also, the benefits and 
risks of the study and how they were selected to take part in the study were communicated 
to them. A copy of the signed consent form was given to the participant/guardian and the 
other one kept by the lead investigator for future reference. The assent form is also included 
as Appendix 2. 
3.U.3 Informed ascent 
Infonned ascent was obtained from the adolescents who were less than 18years whose 
guardian had consented for them to participate in the study. The ascent form contained 
names and telephone numbers of the Principal Investigator and the contact email of the 
secretary of the Cameroon Baptist Convention Health Service Ethical Committee. Prior to 
all interviews, the interviewers reviewed the ascent form with the participant. Participants 
were to sign the ascent form before answering the questionnaire. Participants were informed 
of the rational of the study, the procedures and length of the quantitative interviews. Also, 
the benefits and risks of the study and how they were selected to take part in the study were 
communicated to them. A copy of the signed ascent form was given to the guardian of the 
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minor and the other one kept by the lead investigator for future reference. The infonned 
consent fonn has been shown as Appendix 1. 
3.11.4 Confidentiality 
The confidentiality of the participants was protected. The questionnaires and data extraction 
forms were identified using numbers and codes. Names of participants or their guardians 
were not taken. All collected questionnaires and data extraction fonns were kept in locked 
up in a cabinet. For all data entries in the software used, only codes were used to differentiate 
the entries. Participants have not been reported by names in the resul ts of the study. 
3.11.5 Privacy 
The privacy of participants was ensured. The questionnaires were administered to them 
while they were waiting to refill drugs in their separate adolescent section. 
3.11.6 Benefits 
The participants and guardians were told that there were no direct benefits for participating 
in the study and that the care they will be given during their stay in the hospital was not 
dependent on their participation in the study. However, they were infonned that, the 
information provided could help us to understand the detenninants of adherence and make 
possible recommendations to stake holders on how to improve on adherence in adolescents. 
3.11.7 Risks 
No biological samples were collected, and participants were not exposed to any physical 
danger whilst they took part in the study. They however spent about 15mins of their time 
answering the questions. 
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3.1 1.8 Right to withdraw 
Respondents' participation in the study was purely voluntary and they could choose not to 
participate in the study, withdraw consent at any time, and refuse to answer any question in 
the process of the interview if they decided to do so and it was not compulsory to explain if 
they choose to withdraw from the study. Participants were informed that their decision not 
to participate in the study will not affect them negatively in any way. 
3.11.9 Data Management and Protection 
Data from this research was entered into excel and there was a password on the computer 
assessable only to the PI. There were no names or identifying information on the data entries. 
3.11.10 Compensation 
The participants and their guardians were not paid or given any form of reward for 
participating in this research. 
3.12 Chapter Summary 
Chapter three has discussed the methods used in the study. It has explained the study design, 
study area, sample size calculations, sampling, data collection, processing and analysis. The 
chapter has also explained the study variables and how each was measured. Issues of ethics 
at administrative and individual level have also been indicated in this chapter. The following 
chapter therefore presents the results of the collected and analysed data in relation to the 
study objectives. 
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CHAPTER FOUR 
RESULTS 
4.0 Introduction 
This chapter presents the results of the study. The first part of the chapter describes the study 
participants. The levels of adherence to ARVs, determinants of adherence - which are sub-
divided into demographic, clinical, socio-cultural, health service and other characteristics 
that may affect adherence - are then presented. The chapter also examines facility readiness 
to adolescent HIV care as well as treatment outcomes of adolescents. 
4.1 Demographic Characteristics of Participants 
Table 5 presents results on the socio-demographic characteristics of the study participants. 
There were more females (55%) than males (45%). The mean age of the participants was 
14.8years (SO = ±2.9). A greater proportion of the adolescents (43%) were young (10-
14years). 
The participants were also categorized based on their occupational status. In this respect, 
more than half of them were students (63%), while the rest (37%) were working. 
Additionally, place of residence was used to group the participants and the majority reported 
residing in urban areas 329 (75%). A greater proportion of the adolescents live with their 
parents (67%) and majority were Christians (90%). Most of the participants use commercial 
transportation (which is dominantly taxi) to travel to the treatment centre, taking less than 
30 minutes. 
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Table 5: Socio-demographic Characteristics of Participants 
Characteristics Total Male, n (%) Female, n 
(%~ 
Age in years, M (SD) 14.79(±2.92) 14.39(±2.91) 15.10(±2.99) 
Age categories 
10-14 197 (43.3) 101 (22.2) 96 (21.2) 
15-17 139 (30.7) 58 (12.7) 81 (17.9) 
18-19 118 (25.8) 45 (9.9) 73 (15.9) 
Missing 1 (0.2) 1(0.2) 0 
Total 455 (100) 205 (45) 250 (55) 
Level of Education 
None 33 (7.3) 13 (2.9) 20 (4.4) 
Primary 130 (28.5) 72 (15.8) 58 (12.7) 
Secondary 268 (58.9) 112 (24.6) 156 (34.3) 
Tertiary 14 (3.1) 6(1.3) 8 (1.8) 
Missing 10 (2.2) 3 (0.6) 7 (1.6) 
Total 455 (100) 206 (45.2) 249 (54.8) 
Residence 
Urban 333 (73.1) 152 (33.4) 181 (39.8) 
Rural 114 (25.1) 48 (10.5) 66 (14.5) 
Missing 8 (1.8) 3 (0.7) 5(1.1) 
Total 455 (100) 203 (44.6) 252 (54.4) 
Occupation 
In school 365 (80.2) 179 (39.3) 186 (40.9) 
Working 22 (4.8) 6 (1.3) 16(3.5) 
Missing 68 (15) 20 (4.4) 48 (10.6) 
Total 455 (100) 205 (45) 250 (55) 
Religion 
None 20 (4.4) 10 (2.2) 10 (2.2) 
Christian 408 (89.7) 179 (39.3) 229 (50.3) 
Islam 16 (3.5) 10 (2.2) 6 (1.3) 
Others 8 (1.8) 4 (0.9) 4 (0.9) 
Missing 3 (0.6) 2 (0.4) 1 (0.3) 
Total 455 (100) 205 (45) 250 (55) 
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Characteristics Total Male, n (%) Female, n 
(%) 
Category of Persons living 
with Adolescents. 
Parents 295(64.8) 139(30.5) 156(34.3) 
Guardians 144 (31.6) 59(13) 85 (18.7) 
By myself 8 (1.8) 3 (0.6) 5 (Ll) 
Missing 8 (1.8) 5 (1.1) 3 (0.7) 
Total 455 (100) 206 (45.2) 249 (54.8) 
Transport means 
Walking 35 (7.8) 18 (3.8) 17 (3.8) 
Commercial transport 418(91.8) 187 (41) 231 (50.7) 
Missing 2 (0.4) 1 (0.2) 1 (0.2) 
Total 455 (100) 205 (45) 248 (55) 
Time taken to hospital 
<30minutes 150(33) 78 (17.1) 72 (15.9) 
30minutes 84 (18.4) 30 (6.7) 54 (11.7) 
31mins - Ihour 140 (30.8) 61 (13.6) 79 (17.2) 
>1 hour 78 (17.1) 34 (7.5) 44 (9.6) 
Missing 3 (0.7) 1 (0.2) 2 (0.2) 
Total 455 (l00) 204 (45) 251 (55) 
4.2 Clinical Characteristics 
Results on clinical characteristics of participants indicated that 82% were on first line 
regimens of ARVs, while 18% were on second line (see Table 6). Only 3 of the participants 
(0.7%) were on third line regimen. The average duration of treatment was 67.3months (SD= 
±46.6). Duration on treatment was further grouped into three categories as shown in Table 
7. About three quarters of them had been on treatment for at least 24 months. The average 
age of initiation into treatment was 9.3 months. Regarding hospital visits, 47% of the 
participants visited the hospital every two months. 
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Table 6 Clinical Characteristics of Participants by Sex 
Characteristic Total, n (%) Male, n (%) Female, n 
{%! 
Type of drug 
First line 352 (77.4) 153 (33.6) 199 (43.7) 
Second line 75 (16.5) 39 (8.6) 36 (7.9) 
Third line 3 (0.7) 2 (0.5) 1 (0.2) 
Missing 25 (5.5) 9 (2) 16(3.5) 
Total 455 (100) 203 (44.7) 252 (55.3) 
Duration on treatment 
(months) M(SD) 67.3 (±46.6) 66.82 (±46.3) 68.15 (±47.4) 
6-12 34 (7.6) 14 (3.1) 20 (4.5) 
13-22 41 (9) 23 (5) 18 (4) 
24+ 380 (83.4) 168 (36.9) 212 (46.5) 
Total 455 (100) 205 (45) 250 (55) 
Age at first clinic visit 
(months) M(SD) 9.27 (±5.12) 8.94 (±5.4I) 9.57 (±4.87) 
Transfer into present facility 
Yes 41 (9) 20(4.4) 21 (4.6) 
No 406 (89.2) 183 (40.2) 223 (49) 
Missing 8 (1.7) 2 (0.4) 6 (1.3) 
Total 455 (100) 205 (45) 250 (55) 
Frequency of hospital visits 
Once a month 180 (39.6) 60 (13.1) 120 (26.4) 
Every two months 212 (46.6) 115 (25.3) 97 (21.3) 
Every three months 49 (l0.8) 24 (5.3) 25 (5.5) 
Others 8 (1.8) 3 (0.7) 5 (1.1) 
Missing 6 (1.3) 2 (0.4) 4 (0.9) 
Total 455 (100) 204 (44.8) 251 (55.2) 
The drug types used by the participants with their codes and full names have also been 
shown in Table 7. Most of the participants were on efavirenz based regimens. 
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Table 7 ARV drug types used by participants with their code names 
Drug type N(%) ARVCode Full Name 
TDF/3TC/ATV/r Tenolam Atazanavir First and second line 5 (1.2) 
ABCl3TClEFV Abacalam Efavirenz First and Second line 
8 (1.9) 
ABC/3TC/LPVI r Abacalam Lopirito First and Second line 7 (1.6) 
ABC/3TC Abacalam Second line 5 (1.2) 
ABC/ATZ Abacavirl Atazanavir Second line I (0.3) 
AB C/3TCINPV Abacalam Nevirapine First and second 4 (0.9) 
ABC/3TCIEFV Abacalam Efavirenz First and second 21 (4.9) 
AT Z/3TCINVP Atazanavir Nevirapine First and second 40 (9.5) 
AZT/3TClEFV Douvir Efavirenz First 23 (5.3) 
AZT/3TCINVP Douvir Nevirapine First 58 (13.7) 
AZT/3TC/ATV/r Atazanavir-rito First and second 2 (0.6) 
ABC/3TCINPV Abacalam Nevirapine First and second 4 (0.9) 
AB C/3TCINPV Abacalam Efavirenz First and second 6 (1.4) 
AZT/3TClEFV Douvir Efavirenz First 23 (5.3) 
AZT/3TClNVP Lamivudine Zidovudine First 61 (14.5) 
Nevirapine 
AZT/3TC/EFV Lamivudine Zidovudine First 10(2.3) 
Efavirenz 
TDF/3TC/LPV/r Tenolam Lopi-rito First and second 3 (0.7) 
TDF/3TCfLPV IC Tenolam efavirenz Lopi-rito First and second I (0.3) 
TX Cotrimox 
TDF/3TC/EFV Tenolam Efavirenz First 144 (33.5) 
TDF 13TCIA  TVT/r Tenofovir Lamivudine First and Second 1 (0.3) 
Atazanavir 
DRV/rfDTG/ETV Darunavir Third 
3 (0.7) 
fDolutegravirfEtravine 
4.3 Trends in yearly enrolment of participants into treatment 
Figure 8 shows trends in yearly enrolment of participants into treatment between 2002 and 
2018. Generally, the number of adolescents enrolled into treatment on yearly basis has been 
on the increase albeit fluctuating less than 10 adolescents enrolled in 2002 but by 2016 about 
70 were enrolled. 
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80 
70 
60 
~e  50 c 
~40 
~ 
§ 30 
z 
20 
10 
o 
.J:.."'~'" !>~" ,.!<)~~q,_",OJ ~I:I ~"'~." ~ ~ t'." t'.!o ~ ~q, 
.,,""- .,,""- ."r;§) .,," .,,<:S" .,,\)- .,," .,," ~ .,,1:1 ~ .,,1:1 .,,1:1 .,,1:1 .,,1:1 .,,1:1 .,,1:1 
Year 
Figure 8: The distribution of adolescents by year enrolled into treatment 
4.4 Distribution of Adolescents by Facility 
The sampled health facilities providing health services to HIV infected adolescents across 
the study area were also examined. Results show that the Regional Hospital Limbe (RHB) 
accounted for 35% of the total number of participants in the study (Figure 9). It was followed 
by the Baptist Hospital Mutengene (20%). The Tiko District Hospital recorded the lowest 
number, less than 5%. 
40 
35 
C..  30 
~ 25 
S 20 
= 15 
~ 10 
~ 5 
0 • I • I I • I • .. 
Figure 9: Participant distribution according to health facility 
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·1.5 ARV Adherence levels 
Determining the level of ARV adherence was the first specific objective of the study. The 
level of adherence to ARV drugs was measured through self-report and medication 
possession ratio. The results in this regard are presented below. 
4.5.1 Self- Report ARV Adherence 
As noted in chapters two and three, self-report ARV adherence is measured based on a 30-
day recall of pills taken. In this study, it was calculated as a proportion of the number of 
pills taken to the number of pills prescribed within a period of 30 days. Participants with a 
self-report measure of 95% and above were considered adherent while the non-adherent 
adolescents had less than 95%. Figure 10 shows the results on self-report adherence. Some 
336 (82.96%) of the participants were adherent to ARV treatment and the remaining 69 
(17.04%) were non-adherent. Hence, the self-report measure of adherence was 83%. 
90% 83% 
80% 
70% 
60% 
50% 
40% 
30% 
20% 17% 
10% 
0% 
Adherent No•n-adher ent 
Figure 10: Percentage distribution of participants by Self-Report Adherence 
4.5.2 Medication Possession Ratio (MPR) 
The medication possession ratio (MPR) was calculated as the sum of the days of treatment 
supplied for all ART prescriptions filled, within the refill interval divided by the number of 
days during that same time period. Based on this formula, participants with an MPR of95% 
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and above are considered adherent and vi· ce versa. A to tal f 418 adolescents had data for 0 
MPR. From the results obtained with the MPR formula, 307 (73.4%) of the participants 
were adherent whereas III (26.6%) of them were non-adherent. Figure 11 shows adherence 
as measured using the MPR formula. 
80% 
73% 
70% 
60% 
50% 
40% 
30% 23% 
20% 
10% 
0% 
Adherent Non-adherent 
Figure 11: Adolescents Adherence levels using the MPR Measure 
Given that adherence as measured by self- report measure and MPR was 83% and 73.4% 
respectively. the hypothesis that adherence levels among adolescents was low has been 
rejected. 
Adherence was shown through MPR to be lower than the self- report measure. The 
relationship between the self-report measure and MPR was assessed. Only the participants 
who had data for both MPR and self-report were considered. A total of 82 participants had 
missing data on both MPR and self-report adherence. The Kappa statistics was used to 
assess the level of agreement between the two measures. The level of agreement was 66% 
(p == 0.54). Based on the Kappa scale, the 66% agreement observed indicated that there is 
substantial agreement between self-report and the medication possession ratio adherence. 
For the purposes of this study, the self-report measure will be used for further analysis to 
assess the determinants of treatment adherence among adolescents since adherence as 
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me asured thro u gh se If- repo rt was hI· g her than that of MPR even though the difference was 
not statistically significant. 
Table 8 Relationship between Self-Report adherence measure and Medication 
Possession Ratio 
MPR 
Self-Report Adherent N (%) Non-Adherent N (%) Total 
Adherent N (%) 232 (74.8) 78 (25.2) 310 
Non-adherent N (%) 47 (74.6) 16 (25.4) 63 
Total 279 94 373 
.... 6 Determinants of Adherence 
Assessing the detenninants of adherence was the second specific objective of this study. 
The determinants of adherence were classified into socio-demographic factors, socio-
cultural, health service factors, patient factors and other factors. 
4.6.1 Socio-demographic factors and Adherence 
The socio-demographic detenninants of adherence considered in the study were age, sex, 
educational level. place of residence, religion, travel means to hospital and whether the 
adolescents lived with their parents, guardians or alone. Only variables with complete 
entries for both adherence and the particular variable were considered, that is, all missing 
variables were excluded. Table 9 shows the results from bivariate or chi-square test of 
independence analysis of the relationship between socio-demographic factors and self-
reported adherence. According to the results in Table 9, early adolescents reported the 
highest adherence with an adherence level of 87.4%. The adolescents with the lowest 
adherence were those in the age category of 18-19 years with an adherence level of 76.4%. 
The relationship between age and adherence was statistically significant (p= 0.05). 
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In addition, adherence was compared between male and female adolescents. A higher 
proportion of males (84.3%) were adherent than their female counterparts (81.7%). 
However, the difference was not statistically significant (p= 0.49), implying that the 
observed difference in= adherence between them probably occurred by chance. 
In terms of participants' level of education, the categories considered included: no formal 
education, primary, secondary and tertiary education of participants. Adherence was highest 
among those who were in secondary school (88.1 %). Adolescents who had other forms of 
education such as vocational training had the lowest adherence (48.5%). The difference in 
adherence between the educational levels was statistically significant (p < 0.01). 
Furthermore, the difference in adherence was also compared between adolescents living in 
urban and rural areas. Rural resident adolescents had higher adherence (83.5 %) compared 
to those residents in urban areas. However, the observed difference in adherence between 
urban and rural adolescents was not statistically significant (p= 0.75). 
Living with parents, guardians or alone was also one of the determining factors of adherence 
considered. Adolescents living with parents had higher adherence (83.9 %) when compared 
with those living with a guardian or alone. Adolescents living alone reported the lowest 
adherence level (62.5%). The difference in adherence was however not statistically 
significant (p = 0.28). 
With regard to religion, the same level of adherence (84.6%) was observed across Christians 
and Muslims. Adolescents who indicated to belong to other religions especially the African 
religion had the lowest adherence rate of 59.3%. The difference in adherence between the 
various categories of religion was statistically significant (p =0.03). In terms of means of 
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travel to the hospitals, the same rate of adherence (82.9) was observed irrespective of the 
means of transport used to get to the treatment facility. 
Table 9 Relationship between adherence and socio-demographic factors 
Self-Report Adherence 
Demographic factor Adherent n (%) Non-Adherent n (%) P-value 
Age categories of 
adolescents (in years) 
lO-14 153 (87.4) 22 (12.6) 
15-17 98 (82.4) 21 (17.6) 0.05 
18-19 84 (76.4) 26 (23.6) 
Total 335 69 
Sex 
Male 156 (84.3) 29 (15.7) 
Female 179 (81.7) 40(18.3) 0.49 
Total 335 69 
Educational level 
None 16 (48.5) 17 (51.5) 
Primary 100 (85.5) 17 (14.5) 0.00 
Secondary 207 (88.1) 28 (11.9) 
Tertiary 9 (69.2) 4 (30.8) 
Total 332 66 
Residence 
Urban 243 (82.1) 53 (17.9) 
Rural 81 (83.5) 16 (16.5) 0.75 
Total 324 69 
Live with 
Parents 218 (83.9) 42 (16.1) 
Guardians 108 (82.4) 23 (17.6) 0.28 
Alone 5 (62.5) 3 (37.5) 
Total 331 68 
Religion 
Christianity 307 (84.6) 56 (15.4) 
Muslim 11 (84.6) 2 (15.4) 0.03 
Others 16 (59.3) 11 (40.7) 
Total 334 69 
Travel means 
Walking 29 (82.9) 6 (17.1) 
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Self-Report Adherence 
Demographic factor Adherent n (%) Non-Adherent n (%) P-value 
Commercial transport 306 (82.9) 64 (17.1) 0.70 
Total 335 69 
Time taken to hospital 
< 30 mins 109 (76.2) 34 (23.8) 
30 mins 61 (88.4) 8 (11.6) 0.07 
30 mins-one hour 104 (85.5) 18 14.5) 
> one hour 60(87) 9 (13) 
Total 334 69 
Notes: Sex, age and means of travel each had 51 participants with missing data, who have been excluded from 
the analysis. Educational level had 57 entries with missing data, and these have also been excluded. As for 
place of residence. 62 entries had missing data. Religion and distance to hospital each had 52 missing values. 
All missing values were excluded from the analysis. 
·t,6.2 Health Service factors 
The relationship between health service factors and adherence is shown in Table 10. The 
results showed that adolescents who had long waiting time in the hospital had a lower 
adherence (60.6 %) compared to the others who were not experiencing long waiting time 
(82.9%). 
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Table 10: Health Service Factors and Adherence 
Self-Report Adherence 
Health service Adherent Non- adherent P-value 
factor n (%) n (%) 
Experienced long 
waiting time 
Yes 37 (60.6) 11 (39.4) 
No 214 (82.9) 44 (17.1) 0.01 
Total 251 55 
Experienced poor 
attitude of hospital 
staff 
Yes 23 (62.7) 5 (37.3) 
No 226 (80.1) 47 (19.9) 0.01 
Total 249 52 
Notes: Long waiting time had 149 missing values and experienced poor attitude from hospital staff 
had 154 missing values. All these missing values were excluded from the analysis. 
This difference in adherence was further shown to be statistically significant (p = 0.01). The 
attitude of staff was also one of the determinants of adherence among adolescents that were 
studied. Adolescents who reported experiencing poor attitude from health staff had lower 
adherence (62.7%) compared to the others (80.1 %). The difference in adherence comparing 
those who indicated poor attitude from health staff and those who had not experienced such 
poor attitude was statistically significant (p = 0.01). 
4.3.3 Socio-cultural factors and Adherence 
The use of traditional medicines and religious beliefs were some of the socio-cultural factors 
of adherence that the study took into consideration. A summary of the relationship between 
socio-cultural factors and adherence is shown in Table II. Out of the 37 adolescents who 
reported using traditional medicines, 69.4% were adherent. On the contrary, majority of the 
participants who were not using traditional medicines (344) had a higher adherence rate of 
83.3%. This difference in adherence level was statistically significant (p= 0.01). 
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Likewise. the relationship between religious beliefs and adherence was also examined. 
Religious beliefs included being healed spiritually or by prayers. The results showed a lower 
adherence rate (78.3%) among those who had these beliefs as compared to those who did 
not (82.9%). The difference in adherence was, however, not statistically significant. 
Some adolescents pointed out that they saw no need for the drugs. In this category, 
adherence rate (78%) was relatively lower than that of adolescents who said they saw the 
need for drugs (83.7%). The difference in adherence between them was, however, not 
statistically significant (p= 0.06). 
Table 11 Relationship between Socio-cultural factors and Adherence among 
Adolescents 
Self-Report Adherence 
Factor Adherent n Non-adherent P-value 
(%) n(%) 
Ever used 
traditional 
medicines 
Yes 25 (69.4) 11 (30.6) 
No 275 (83.3) 55(16.7) 0.01 
Total 300 66 
Received spiritual 
healing before 
Yes 36(78.3) 10 (21.7) 
No 277 (82.9) 57 (17.1) 0.25 
Total 313 67 
Not in need of drugs 
Yes 71 (78) 20 (22) 
No 242 (83.7) 47 (16.3) 0.06 
Total 313 67 
Notes: The use of traditional medicines had 89 missing values while religious beliefs a d t' d 
of drugs each had 75 missing values. The missing values were all excluded from the ~a~~i~n nee 
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4.6.4 Patient Factors and Adherence 
Patient factors may also determine how well the patients adhere to ARV drugs. There are a 
host of patient factors which determine adherence. In this study, the following patient factors 
have been considered, namely, medication related side effects, internalized stigma, 
forgetfulness to take pills, lost pills, busy, tired, waking up early and not understanding the 
treatment regimen. 
Medication related side effects was reported by some adolescents to hinder adherence. Out 
of the 391 adolescents who responded to the question on side effects, 17% reported side 
effects as one of the reasons for poor adherence. Findings revealed that adherence was lower 
(66.3 %) among adolescents who experienced side effects compared to adolescents who did 
not report such effects (85.9 %). The observed difference in adherence was statistically 
significant (p< 0.01). 
Furthermore, internalized stigma was also assessed as a determinant. Internalized stigma is 
that which an individual feel because they have a particular condition, in this case HIV. 
From the 398 adolescents who responded to the questions, 190 (48%) were experiencing 
internalized stigma. When adherence levels were compared between those experiencing 
internalised stigma and those without, it was noted that adolescents who were experiencing 
internalized stigma were adhering less to treatment compared to their counterparts who were 
not having any issues of internalized stigma and the difference was statistically significant 
(p = 0.01). 
Additionally, being HIV positive does not rule out the possibility of other illnesses among 
adolescents. Adolescents in this study reported the occurrence of other illness as a reason 
for poor adherence. It was realized that, adolescents experiencing other form of illnesses 
were less adherent compared to others who were not ill. Their adherence was 70% compared 
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to 87% for those with no co-morbid conditions. Further analysis showed a statistically 
significant relationship between adherence to ARVs and having other illnesses (p = 0.0). 
Waking up early for school or for daily activities was another determinant of adherence that 
was assessed. A total of 164 adolescents reported waking up early and only half of this 
number were adherent to treatment. Adherence among adolescents who were waking up 
early for school, work or other reasons was lower (79.4%) when compared to the other 
adolescents who did not report waking up early as a problem (83.8%). When the difference 
in adherence was compared between the two groups, it was not statistically significant (p = 
0.28). 
Lastly, some adolescents had difficulties understanding the treatment regimen and this was 
also having an effect on their treatment adherence. A greater majority of the adolescents 
understood the regimen and their adherence was higher (83.9%) compared to those who did 
not (69.8%). After comparing the difference in adherence using the chi-square-statistics, the 
observed difference in adherence between the two groups was statistically significant 
(p=O.02). Table 12 shows the relationship between some patient factors and adherence. 
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Table 12 Relationship between Patient Factors and Adherence 
Self-Report Adherence 
Factor Adherent n (%) Non-adherent n (%) 
P-value 
Experienced Side 
effects 
Yes 45 (66.3) 22 (33.7) 
250 (85.9) 43 (14.l) 0.01 No 
Total 295 65 
Experienced 
internalized stigma 
Yes 13 3(73.9) 18 (16.l) 
No 188 (91.3) 47 (8.7) 0.01 
Total 321 65 
Lost pills 
Yes 22 (78.6) 6 (21.4) 
No 289 (82.6) 61 (17.4) 0.60 
Total 311 67 
Being busy 
Yes 108 (74) 28 (26) 
No 206 (88) 38 (22) 0.01 
Total 314 66 
Had other illnesses 
Yes 70 (70) 30 (30) 
No 240 (87) 36 (23) 0.01 
Total 310 66 
Waking up early 
Yes 108 (79.4) 28 (20.6) 
No 202 (83.8) 39 (16.2) 0.28 
Total 310 67 
Not understanding 
regimen 
Yes 30 (69.8) 13 (30.2) 
No 282 (83.9) 54(16.1) 0.02 
Total 312 67 
Note: All the patient factors had missing values: experiencing side effects had 95 missing values, 
experiencing stigma had 69 while losing pills had 77 missing values. Being busy had 75 missing 
values, having other illnesses had 79, waking up early had 78 and not understanding the treatment 
regimen had 76 missing values. All these missing values have been excluded from the analysis. 
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".6.5 Other factors of Adherence 
The other factors of adherence here included stigma, running out of pills, away from home 
and frequency of medications. The relationship between adherence and these factors was 
assessed by bivariate analysis using the chi-square statistics. Table 13 shows a summary of 
the other determinants of adherence. 
Table 13: Other Determinants of Adherence 
Self-Report Adherence 
Factor Adherent N Non-adherent P-value 
(%) N (%) 
Experienced Stigma 
Yes 107 (72.8) 27 (17.2) 
No 207 (88.5) 40 (11.5) 0.01 
Total 314 67 
Number of times pills are taken 
Once daily 131 (82.4) 28 (17.6) 
Twice daily 178 (84.8) 32 (15.2) 0.54 
Total 309 60 
Being away from Home 
Yes 131 (73.6) 47 (26.4) 0.01 
No 169 (89.4) 20 (10.6) 
Total 300 67 
Ran out of pills 
Yes 24 (54.5) 20 (45.5) 0.01 
No 273 (85.9) 45 (14.1) 
Total 297 65 
Note: Experiencing stigma had 74 missing values and the frequency of medication had 86 missing values. 
Being away from home had 88 missing values and running out of pills had 9These missing values were 
excluded from the analysis. 
Stigma (externalised) was reported as one of the reasons for not taking drugs. A total of 391 
responded to the question on stigma and 149 of them (38%) indicated that they were 
stigmatized because of the infection and it was affecting their ability to adhere to treatment. 
The adherence level of the majority who were not experiencing stigma (88.5%) was higher 
than adolescents experiencing some form of stigma (72.8%). The difference between the 
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two groups of adolescents in tenns of stigma and adherence was statistically significant (p 
=0.00). 
The frequency of medications or number of times pills are taken was also one of the factors 
of adherence that was assessed. There was no significant difference comparing adherence 
between adolescents who were on once daily and those on twice daily pills (p = 0.54). Being 
away from home was also assessed as a determinant of adherent. The relationship with 
adherence was significant (p < 0.01). Also, running out ofpilIs was significantly associated 
with adherence. 
4.7 Multivariate analysis of tbe determinants of adherence 
To further examine the detenninants of self-reported adherence, factors that showed 
statistical association at the bivariate level were pulled into a binary and multiple logistic 
regression models and odd ratios were estimated. Out of the 28 variables included in the 
bivariate analysis, 12 showed statistical association with self-reported adherence. These 12 
factors were then further examined using binary and multiple logistic regression models. 
Table 14 shows the results. 
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Table 14 Relationship between Adherence and its Determinants in Multiple Logistil' Regression Analysis 
Factor Adherent Non-adherent OR 95%CI p- AOR 95% CI p-
n (%! n {%) Value Value 
Education 
None (Ref) 16(48.5) 17(51.5) 
Primary Secondary 100(85.5) 17(14.5) 1.26 (0.66.2.4) 0.49 0.71 (0.26, 1.97) 0.51 
Secondary 207(88.1) 28(11.9) 0.38 (0.11,0.38) 0.14 0.78 (0.09, 6.14) 0.81 
Tertiary 9(69.2) 4(30.8) 0.16 (0.07,0.38) 0.0 0.45 (0.13, 1.58) 0.21 
(Age categories (years) 
1O-14(Ref) 153(87.4) 22(12.6) 
15-17 98(82.4) 21(17.6) 0.67 (0.35, 1.28) 0.23 1.06 (0.38, 2.97) 0.93 
18-19 84(76.4) 26(23.6) 0.46 (0.25, 0.87) 0.02 0.67 (0.25, 1.79) 0.43 
Experience long waiting 
time 
Yes (Ref) 37(60.6) 11(39.4) 
No 214(82.9) 44(17.1) 2.75 (1.39,5.49) 0.00 2.24 (0.81,6.18) 0.12 
Experience poor attitude of 
hospital staff 
Yes (Ref) 23(62.7) 11(37.3) 
No 226(80.1) 47(19.9) 2.73 (1.2,6.2) 0.00 1.01 (0.26,3.84) 0.99 
Ever used traditional 
medicines 
Yes(Ref) 25(69.4) 11(30.6) 
No 275(83.3) 55(16.7) 2.2 (1.02,4.73) 0.00 1.00 (0.33,3.07) 0.99 
Experienced side effects 
Yes(Ref) 45(66.3) 22(33.7) 
No 250(85.9) 43(14.1) 2.96 (1.63, 5.38) 0.00 2.63 (1.14, 6.09) 0.02 
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Factor Adherent Non-adherent OR 95%CI p- AOR 95%Cl /'-
n{%} ~ Val," Value 
Experienced internalized 
stigma 
Yes(Ref) 133 (73.9) 18 (16.1) 
No 188 (91.3) 47 (8.7) 3.69 (2.05,6.64) 0.00 2.51 (1.04, 6.04) 0.04 
Being Busy 
Yes (Ref) 108 (74) 28 (26) 
No 206 (88) 38 (22) 2.59 (1.51. 4045) 0.00 1.39 (0.67,2.89) 0.38 
Had other Illness 
Yes(Ref) 70 (70) 30 (30) 
No 240 (87) 23 (36) 2.88 (1.64,4.97) 0.00 1.53 (0.69,3.37) 0.29 
Not understanding regimen 
Yes(Ref) 30 (69.8) 13 (30.2) 
No 282 (83.9) 54 (16.1) 2.26 (1.\,4.16) 0.02 1.96 (0.71, 5042) 0.19 
Felt Stigmatised 
Yes(Ref) 107 (72.8) 27(17.2) 
No 207 (88.5) 40 (11.5) 2.87 (1.67,4.92) 0.00 0.92 (0040,2.13) 0.85 
Religion 
Christian(Ref) 307 (84.6) 56 (1504) 
Muslim 11 (84.6) 2 (15.4) 1.00 (0.22, 4.65) 0.99 1.69 (0.25, 11.08) 0.59 
Others 16 (59.3) II (40.7) 0.27 (0.12, 0.6) 0.01 2044 (0.16,37.25) 0.52 
Away from home 
Yes(Ref) 131 (73.6) 47 (26.4) 
No 169 (8904) 20 (10.6) 3.03 (2.58,9.89) 0.00 1.79 (0.83,3.84 0.14 
Ran out of pills 
Yes(Ref) 24 (54.5) 20 (45.5) 
No 273 (85.9) 45 (14.1) 5.06 (1.71,5.37) 0.00 2.09 (0.78,5.62) 0.14 
Note: ref= reference category; OR = Odds Ratios; AOR=Adjusted Odds Ratios 
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From the multivariate logistic regression analysis, only two variables significantly predicted 
adherence after potential covariates were adjusted for. These were medication side effects and 
internalised stigma. The odds of adhering to treatment was relatively higher in those who did 
not experience side effects compared with those who did experience side effects (AOR=2.6; 
95% CI= 1.14, 6.09; P = 0.02). It was also observed that adolescents who did not experience 
internalized stigma were 2.7 had a higher odds of adhering to treatment (AOR = 2.66; 95% CI 
.. 1.04,6.04; P = 0.04). Based on these results, hypothesis two which states that, adherence to 
ART among HIV positive adolescents who are on treatment is determined by demographic and 
socio-cultural, health service factors has been rejected. 
~.8 Determinants of both self-report and the Medication Possession Ratio adherence 
Earlier analysis had shown that there is a substantial agreement between the two measures of 
adherence. However, given that there were some discrepancies between the self-report measure 
and the medication possession ratio, there is need to assess the determinants of adherence when 
the two measures are combined. For the bivariate analysis, religion, distance to health facility 
and running out of pills showed statistical association with adherence. These variables were 
pooled into a multivariate model and none of them showed a significant relationship with 
adherence after adjusting for other co-variates. Details of these results are presented in Table 15. 
4.9 Cballenges of Adherence among Adolescents 
Adhering to life-long medications like ARV continues to pose challenges especially among 
adolescents. This study had as part of its objectives to investigate some of the challenges of 
adolescents who are on ARV medication. Investigations revealed that adolescents face a 
number of challenges to adherence including stigma (59%), forgetting to take medications 
t59%), being in school (53%) and tired of taking too many pills (50%). In this regard, 
hypothesis 3 fails to be rejected as the adolescents were challenged by a number of factors. A 
summary of the challenges of adherence has been shown in Table 16. 
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Table 15: Detem1inants of both self-report and the Medication Possession Ratio adherence 
Factor Adherent Non-adherent OR 95%CI p- AO 95%CI p-
{SR&MPR~ n {%) (SR&MPR~ D {%} value R vlllue 
Distance to health 
facility 
30mins(Rej) 71 (53.8) 61 (46.2) 
Less than 30mins 41 (66.1) 21 (33.9) 1.68 0.89,3.14 0.12 1.53 0.8,3.46 0.24 
Between 30m ins to one 76 (66.7) 38 (33.3) I.n 1.02,2.89 0.04 1.55 0.89,2.n 0.12 
hour 
Greater than one hour 43 (67.2) 21 (32.8) 1.76 0.94,3.28 0.08 I.n 0.17,3.09 0.12 
Religion 
Christian(Rej) 216 (64.1) 121 (34.9) 
Muslim 6 (50) 6(50) 0.56 0.11,2.81 0.48 0.89 0.14,5.55 0.90 
Others 9 (39.9) 14 (60.1) 0.31 0.11,0.84 0.02 0.37 0.11,1.11 0.08 
Ran out of pills 
Yes (Rej) 19 (46.3) 22 (53.7) 
No 185 (63) 108 (37) 1.98 1.03,3.83 0.04 1.91 0.96,3.97 0.11 
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Some other difficulties related to adherence that were noted were: running out of pills, being 
busy. dislike for tablets, absence of guardian, at work and feelings of rejection. Adolescents 
further mentioned issues of belief to be healed. taking drugs to make them sick. going to 
church, not wanting to travel with guardian to be some of the issues they face which can 
have a negative influence on ART adherence. 
Table 16 Challenges of Adherence faced by the Adolescents 
Challenge Frequency (N) Proportion (%) 
Stigma 202 59 
Forgetting to take medications 260 59 
Being in school 184 53 
Tired of taking medications 198 50 
High frequency of pills 159 47 
Being out of town 195 47 
Having transport problems 139 40 
Being busy 150 38 
Current Political crisis 150 38 
Financial constraints 118 34 
Sick 91 27 
Not wanting to 65 19 
Waiting time 47 14 
Running out of pills 44 11 
Dislike for tablets 30 9 
Poor attitude of hospital starr 28 8 
Guardian absent 24 6 
At work 4 2 
Note: ·The proportions shown on table 16 are based only on the number that responded to each 
question. Multiple responses were allowed for the challenges of adherence. 
4.10 Improving Adberence among Adolescents 
Given the challenges associated with taking ARV among adolescents, there was a need to 
explore ways of improving adherence. Figure 12 shows the results on participant's 
perspectives on how to improve ARV adherence. 
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80% 
69% 69% 
70% 64% 
60% 
50% 
40% 
32% 
30% 
20% 
10% 
0% I 
Reduce pills Sene! . ",lJinder Medications brought Providers should be 
messages home friendlier 
Figure 12: Participant's perspective on improving adherence 
One of the major challenges earlier mentioned was pill burden. A good number of the 
adolescents (64%) are of the opinion that adherence could be improved by reducing the 
frequency of pills to be taken. Some of them even proposed the use of injections, which 
could last for a month. A few of the adolescents also suggested the use of AR V s in form of 
implants. 
Furthermore, more than half of the adolescents (69%) agreed that sending reminder 
messages via text messages could be a means of making adherence better. This finding was 
aimed at addressing the earlier challenge related to forgetfulness to take medications. 
Additionally, healthcare workers bringing medications to their homes was another method 
of improving adherence that the study evaluated. Findings showed that only 32% of the 
adolescent agreed to medications being brought to their homes by healthcare workers (see 
figure 11). This \vas the response with the lowest proportion, which by implication indicates 
that bringing medications home might not improve on adherence. Moreover, 69% of 
participants suggested that care providers must be friendly in the care delivery process. This 
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proposal was directly related to the fact that the poor attitude of healthcare providers was 
one of the challenges associated with adherence . 
.U  1 Adolescents HIV Treatment Outcomes 
The treatment outcomes of adolescents with HIV was also assessed as one of the study 
specific objectives. The outcomes considered were viral load suppression. CD4 counts and 
retention rates. 
4.11.1 Measures of viral load 
A total of 393 viral load results were extracted from individual adolescent files. The viral 
load results used were those of the most recent test performed. V iral load measurements 
were obtained from patients' files using a data extraction form. From the findings, the viral 
load results ranged from "not detected" to 3,424,122 copies per ml. Adolescents with viral 
loads less than 1000 copies per ml were considered to have viral load suppression. Based 
on this grouping, 276 (70.2%) had a suppressed viral load while 143 (29.8%) had viral loads 
greater than 1000 copies per ml. Figure 13 shows a summary of the viral load results. 
70",) 
60% 
50% 
30% 
40% 
30% 
20% 
10% 
0% 
Viralload suppressed Viral load not suppressed 
Figure 13: Viral load suppression among Adolescents 
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4.11.2 Relationship between Adherence and Viral load 
Adherence to ARV treatment could affect viral suppression. In fact, having a suppressed 
viral load may be indicative of good adherence. From the analysis, 215 (61%) of the 
adolescents who were adherent had a suppressed viral load. It was also seen that 9% of them 
who were adherent did not have their viral loads suppressed. The observed difference in 
viral load suppression between those who were adherent and those who were not was 
statistically significant (p<O.O I). 
Furthermore, self-report and MPR were combined and the relationship with viral load 
suppression assessed. The difference in viral load suppression between those who were 
adherent for both self-report and MPR and those who were not adherent was significant 
(p=O.03). Table 18 shows the relationship between viral load suppression and adherence. 
Table 17 Relationship between Viral load suppression and Adherence 
Type of Viral load Viral load not OR 95%CI p-
Adherence suppressed n (%) suppressed n (%) value 
measure 
Self-report 
Adherent(Ref) 215 (73.6) 77 (26.4) 
Non-adherent 30 (52.6) 27 (47.4) 0.29 0.14,0.59 0.00 
Self-report & MPR 
Adherent(Ref) 39 (26.9) 106(73.1) 
Non-adherent 29 (41.4) 41 (58.6) 0.52 0.28,0.95 0.03 
4.12 CD4 Measurements 
CD4 data was extracted from patient files. Three recent measures of CD4 count were taken. 
A total of 343 adolescents had results for the first CD4 count and 82% of these had CD4 
counts above 200cells/ul. For the second CD4 count, adolescents with CD4 counts above 
200 were higher (87%) while for the third count, it was 89%. This indicates a slight increase 
in CD4 counts among adolescents over time (Figure 14). 
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100% 89% 
87% 
90% 82% 
80% 
70% 
60% 
50% 
40% 
30% 
18% 
20% 
10% •• ····1131%· · •1•1%0% •  
C04(1) C04(2) C04(3) 
_ less than 200cells/ul _ greater than 200cells/ul 
..... linear (less than 200cells/ul) ......... linear (greater than 200cells/ul) 
Figure 14: Measures ofCD4 count 
The relationship between CD4 count and adherence was also assessed. Chi square test of 
independence was used to asses the relationship between adherence and the most recent 
CD4 count results and it was not statistically significant. The CD4 count results were further 
categorised into two; those with counts less than 200 and those above 200 CD4 cells. 
Adherence was higher among those with CD4 counts above 200. However, this observed 
difference was not statistically significant (Table 19). 
Table 18 Relationship between Adherence and CD4 among adolescents 
Adherent n Non-adherent n P-value 
(%) (%) 
CD4 
Below 43 (13.7) IS (4.5) 
200 
Above 229 (69.4) 45 (12.4) 0.12 
200 
4.13 Retention rates 
Retention rates were measured for adolescents who were recruited into treatment between 
January and December 2015. During this period, a total of 257 adolescents were initiated 
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into treatment in the selected health facilities. Their retention rates were calculated at 6, 12 
and 24 months. 
4.13.1 Retention rates at six months 
Table 20 shows retention rates at six months. The Baptist Hospital in Mutengene recruited 
19 adolescents and by the end of six months, two were lost to follow-up. This gave a 
retention rate of 89% at 6 months. The Nkwen Baptist Hospital also recruited 19 and had a 
retention rate of 84% as they recorded two deaths and one lost to follow-up. At the Limbe 
Regional hospital, 30 adolescents were recruited and 6 were absent by the end of 6 months 
giving them a retention rate of 80%. 
Table 19 Retention rates at 6 months 
Facility Total LTFU Deaths Present at end Retention at 
Enrolled{n~ {n~ {n~ of 6months {n~ 6 months (%) 
Baptist Hospital Mutengene 19 2 0 17 89 
Nkwen Baptist Hospital 19 1 2 16 84 
Limbe Regional Hospital 30 6 0 24 80 
St Elizabeth Hospital 70 7 2 61 87 
Kumbo 
Kumba District Hospital 35 4 30 86 
liko District Hospital 6 1 0 5 83 
Regional Hospital Buea 21 2 18 86 
Banso Baptist Hospital 45 2 0 43 96 
Bamenda Regional Hospital 12 1 0 11 92 
Total 257 26 6 225 88 
The largest number of adolescents were recruited in the 8t Elizabeth Hospital Kumbo (70 
enrolments). By the end of 6 months, 7 had been lost to follow-up with two deaths, hence 
retention rate was 87%. The Kumba district hospital had 35 adolescents and by the end of 
six months, 30 were still in treatment giving a retention rate of 86%. The Tiko District 
Hospital on the other hand enrolled the lowest number with just 6 adolescents and had a 
retention rate of 83 % by 6 months. 
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The Regional Hospital. Buea, had 21 adolescents in total; two were lost to follow-up and 
one dead and this gave a retention rate of 86%. The Banso Baptist Hospital enrolled 45 and 
ended with 43 by six months, 96% of the adolescents were therefore retained. This hospital 
bad the highest retention rate at six months. Lastly, the Bamenda Regional Hospital that 
started with 12 adolescents had 11 left by six months scoring a retention rate of 92%. The 
average retention rate for all the health facilities by six months was 88%. 
4.13.2 Retention Rates at 12 months 
Table 21 also shows results on retention rates at 12 months. The retention rates were also 
analysed one year after treatment initiation. The Baptist hospital, Mutengene, had a retention 
rate of 88% as they had one lost to follow-up and one death. The Nkwen Baptist hospital 
recorded one death, two L TFU and scored a retention rate of 81 %. The regional hospital of 
Limbe reported two deaths and six L TFU, this gave them a retention rate of 67%. 
Table 20: Retention Rates at 12 months 
Present at No. present % Present at 
Facility end of LTFU Deaths at end of end of 12 
6months (n} (n} {n} 12mooths{n} Months 
Baptist Hospital Mutengene 17 I I 15 72 
Nkwen Baptist Hospital 16 2 1 13 68 
Limbe Regional Hospital 24 6 2 16 53 
Annex 
St Elizabeth Hospital 61 10 50 
Kumbo 71 
Kumba District Hospital 30 4 0 26 74 
Tiko District Hospital 0 0 5 83 
Regional Hospital Buea 18 3 0 15 71 
Banso Baptist Hospital 43 I 37 82 
Bamenda Regional Hospital II 2 0 9 75 
Total 225 33 6 186 72 
The St Elizabeth hospital ended with 50 out of 61 adolescents that they had at six months; 
they therefore had a retention rate of 82% at 12 months. The Kumba district hospital scored 
a retention rate of 87% after losing three adolescents to follow-up. As for the Tiko district 
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hospital, the retention rate was 100% as no adolescent was lost to follow-up or died. The 
Regional Hospital Buea had 15 adolescents at the end of one year giving them a retention 
rate of83%. The Banso Baptist had a lower rate of86% after losing 5 adolescents to follow-
up with one death. The Bamenda Regional Hospital ended up with a retention rate of 82% 
and accounted for two lost to follow-up. The overall retention rate at 12 months for all the 
health facilities was 85%. 
4.13.3 Retention Rates at 24 months 
The cohort of adolescents were followed retrospectively up to two years. By the end of 12 
months, the Baptist Hospital Mutengene had 13 adolescents from that cohort and by 
December 2017, none was lost giving a retention rate of 68%. The Nkwen Baptist Hospital 
scored 58% as they had one LTFU and one death. The Limbe Regional Hospital Annex lost 
two to follow up and ended with a retention rate of 47% while the St Elizabeth hospital 
scored 49%. The kumba district hospital lost six patients to follow-up, recorded one death 
and ended up with a retention rate of 54%. As for the Tiko district hospital, the retention 
rate was 67% with one LTFU. The Regional Hospital Buea had two cases LTFU and earned 
a retention rate of 62%. Similarly, the Banso Baptist Hospital had a retention of 73% while 
the Bamenda Regional Hospital had a 58% retention rate, which was lower than their score 
at 12 months. The overall retention for all the health facilities at 24 months was 58% with 
149 adolescents retained (see Table 22). 
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Table 21: Retention Rates at 24 months 
Present at No. present % present at 
Facility end of LTFU Deaths at end of24 end of24 
6months {n~ months months 
Baptist Hospital Mutengene 17 0 J3 68 
Nkwen Baptist Hospital 16 1 II 58 
Limbe Regional Hospital Annex 24 2 0 14 47 
St Elizabeth hospital kumbo 61 IS 34 49 
Kumba district Hospital 30 6 I 19 54 
Tiko district hospital 0 4 67 
Regional Hospital Buea 18 0 13 62 
Banso Baptist Hospital 43 33 73 
Bamenda Regional Hospital II 2 0 7 58 
Total 225 33 4 149 58 
In summarily, there were 257 adolescents enrolled into treatment in the 9 selected health 
facilities between January and December 2015. By December 2017, that is 24months later, 
a total of 92 had been lost to follow-up and 16 died hence 149 were left. Further analysis of 
the mortality cases gave an accumulated mortality rate of 5% after two years. There was a 
total of 42 transfer-out cases, 14 in the first six months, 18 in one year and 10 at the end of 
24 months. Figure 15 gives details of the retention rates per health facility considered in the 
study. 
120 
100 
80 
60 
40 
20 
o 111111111111111111111111111 
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.U4 Facility Preparedness towards Care of Adolescents 
To evaluate facility preparedness. a checklist was used which had six different parts: 
leadership, management of ARVs, Programme Protocols, Experience and Staffing and Drug 
Procurement. A summary of the results is shown in Table 23. For leadership, all the 9 health 
facilities had an average score of 5. As for the management of ARV services, the Baptist 
Hospital Mutengene, Kumba District Hospital, Tiko District Hospital, Banso Baptist 
Hospital, and the Bamenda Regional Hospital had an average score of 5. Facilities with a 
score of 4 have adequate staff trained in the management of ARV drugs, have a separate site 
for Adolescent HIV care with all the HIV support programs on site. The Nkwen Baptist 
Hospital had 3.5 because the community network was not well developed. The Limbe 
Regional Hospital Annex and the Buea Regional Hospital scored 3.7 and 4 respectively. 
This was because they had limited experience in management of ARVs and required 
additional training of staff in that aspect. 
As further shown by Table 23, as for programme protocols, except for the Nkwen Baptist 
Hospital, Limbe Regional Hospital and St Elizabeth Hospital, the other 6 facilities had an 
average score of 5. This implies that these 6 facilities had all national programme protocols 
for ARV eligibility, screening and monitoring. Additionally, experience and staffing were 
part of the indicators considered. The Nkwen Baptist Hospital and Limbe Regional Hospital 
had the lowest score of 2.5 each. Furthermore, laboratory capacity was also assessed. The 
Baptist Hospital Mutengene and the Bamenda Regional Hospital all scored 2 out of 2. As 
for the Nkwen Baptist Hospital, the Limbe Regional hospital each had an average score of 
5. The last indicator was drug was drug procurement and most of the facilities had an 
average score of 5. The total average score on 30 was then obtained for each facility. 
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Table 22: Health Facility Readiness to provide care to adolescents 
Health Baptist Nkwen Limbe St Kumba Tiko Regional Banso Bamenda 
facilitylDomain Hospital Baptist Regional Elizabeth district district Hospital Baptist Regional 
Mutengene Hospital Hospital hospital Hospital hospital Buea Hospital 
kumbo Hospital 
Leadership 
Leader 
Model of care 
Average domain score 5 5 5 5 5 5 5 5 
Services 
--,;va 
Comprehensive 
4 4 
services 
Physical space 4 4 
Community 
4 4 
involvement 
Average domain score 5 3.5 3.7 4.3 5 5 5 5 
Program protocols 
management and 
evaluation 
ART protocols 
MIS 
Program M&E 4 4 
Average domain score 5 4.7 4.3 4.6 5 5 5 5 
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E\pcrienCt' and 
staffing 
Experience 2 2 4 
Management, 
training and 4 5 
retention 
Average domain score 5 2.5 2.5 4 5 5 5 5 5 
Laboratory capacity 
Testing capability 4 4 
Quality standards 4 3 4 4 4 4 4 
Average domain score 5 3.5 3.5 4 4.5 4.5 4.5 4.5 
Drug management 
and procurement 
Supply chain 
Pharmacy 
5 4 5 
management 
Financial resources 
for ARV and other 4 
drug procurement 
Average domain score 5 5 5 4.3 5 5 5 5 5 
Total average domain 
scorel30 30 24.3 24 26.2 29.5 29.5 28.5 29.5 30 
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Based on the John Snow Inc (JSI) tool for scoring offacilities, over 75% of the facilities are 
already at stage 5, meaning they need support, maintenance and expansion. According to 
this tool, all sites administering ARVs should be at this stage and are functional and offering 
HIV services to all age groups. However, they still require support to expand and maintain 
the standards. Furthermore, stage 5 facilities could also be used as models to other facilities 
and could be required to offer training for sites at a lower stage. 
The other health facilities are at stage 4, which is the action stage. These are facilities that 
are already providing ARVs. However, there is a need for more support in order to upgrade 
the ARV services with efforts tailored towards the proper and safe use of these services. 
From these results therefore, all the selected health facilities were ready to receive 
adolescents. Based on this premise, hypothesis four fails to be rejected. A summary of the 
facility scores with their stages are presented in Table 24. Even though with varying scores, 
out of the nine facilities considered, seven of them were at stage 5 while two, namely, 
Nkwen Baptist Hospital and Limbe Regional Hospital Annex were in Stage 4. 
Table 23: Health Facility Score and Interpretation of Score 
Health facility Score Stage Meaning 
Nkwen Baptist Hospital 24 4 Action 
Baptist Hospital Mutengene 30 5 Support, maintenance and expansion 
Limbe Regional Hospital Annex 24 4 Action 
St Elizabeth Hospital kurnbo 26 5 Support, maintenance and expansion 
Kumba district Hospital 30 5 Support, maintenance and expansion 
Tiko district hospital 30 5 Support, maintenance and expansion 
Regional Hospital Buea 29 5 Support, maintenance and expansion 
Banso Baptist Hospital 30 5 Support, maintenance and expansion 
Barnenda Regional Hospital 30 5 Support, maintenance and expansion 
4.14.1 Adherence by Health Facility Score 
The goal of health facilities is to provide the best possible care to the clients. One of the 
many possible ways to also asses the performance of a facility in the case of HIV is to 
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measure the adherence of the patients recel. vm. g treatment . tha  t facility The lSI tool has 10 . 
been used above to show how prepared th e lCao CI' 1I't"l es are. The  study therefore went further 
to compare the scores of the fac.l h.t y 'th adhe rence level . Findings revealed that, the WI 
facilities with the highest adherence also had the highest score and vice versa (Figure 16) . 
• score • adherence 
I I I i I I I I I 
BHM NBH LRH SHS KDH TIKO RHB BBH BRH 
Figure 16: Adherence by Facility Score 
·U5 Chapter Summary 
This chapter presented the results of the study. Results suggest that self-report adherence 
was 83% while adherence based on Medication Possession ratio (MPR) was 73.4%. After 
adjusting for potential confounders in multivariate analysis, only two variables significantly 
predicted adherence. The major challenges of adherence reported were stigma and 
forgetfulness to take medications. As for the strategies to improve adherence, majority 
(69%) of the participants advocated the use of reminder messages and also that health 
providers should be friendlier. In relation to treatment outcomes, majority (70%) of the 
participants had suppressed viral loads. Retention rates were highest at 6 months (88%) and 
lowest at 24 months (58%). For facility readiness to care for adolescents, most of the 
selected health facilities were well prepared to receive adolescents as they were in stage 5 
as per the health facility preparedness tool. The next chapter discusses the results presented 
in this chapter. 
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CHAPTER FIVE 
DISCUSSION 
5.0 Introduction 
This chapter discusses the study's results in relation to earlier and related works on HlV 
adherence. Like the results chapter, the discussion is structured along the objectives of the 
study. The discussion specifically focuses on the characteristics of study participants, level 
of adherence, determinants of adherence, challenges ofa dherence, ARV treatment outcomes 
and health facility preparedness towards care of adolescents. The chapter also discusses the 
strength and limitations of study. 
5.1 Clinical characteristics of participants 
Findings suggested that most of the adolescents on treatment were on first line drugs (82%) 
while 17% were on second line medication. Given that some of the adolescents are on 
second line drugs, it raises concerns as this might be an indication that drug resistance is 
gradually setting in and this could be a stage for complications in the near future. Moreover, 
adolescents on treatment still have a longer period ahead of them to be on ARV treatment, 
therefore, switching to second line medication at this age lives much to be desired in terms 
of how long they can last on treatment. In addition, majority of the participants had been 
on treatment for over 24 months. This is not surprising given that most of them were 
perinatally infected and have been on treatment since birth. 
Furthermore, the number of adolescents enrolled per year since 2002 was shown to increase 
over time, with the highest number enrolled in 2016. The increase in enrolment could be 
related to new HIV programmes targeting adolescents that were launched. For instance, the 
Accelerated Care and Treatment for children programme started in 2014 and the 
Adolescents Champion programme, which was launched in 2018, has been involved in 
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school HIV screening, screening of children of HIV infected parents, and follow up to get 
as many infected adolescents as possible enrolled into treatment. 
5.2 Adherence level among adolescents 
This study determined the level of adherence among adolescents. Using the self-report 
measure of adherence, 83% of the participants in the study were observed to be adherent. 
The result in relation to self-reported adherence in this study is in consonance with results 
from Kim et al. (2014) and Firdu and others, which reported adherence levels of 84% and 
791'10 respectively among adolescents(Firdu, Enquselassie, & Jerene, 2017; H. Kim et aI., 
2017). 
The relatively high level of adherence in this study could probably be because counselling 
for adolescents has been improving over time in Cameroon as a whole. and these adolescents 
who are now aware of their status understand the need to take their drugs. A number of 
programmes like the accelerated care and treatment for children programme, adolescents 
champion programme and other NGOs that assist HIV positive persons have been helpful in 
scaling up these counselling programmes targeting adolescents. In addition, adolescents are 
being treated with snacks in many of the health facilities when they visit for refill. There are 
also some Community Based Organisations and Non-Governmental Organisations in some 
facilities that subsidise the cost of viral load tests. All these factors work as enablers, and 
could serve as motivation for some adolescents, especially those who have limited access to 
food and finances. 
The result, however, differ from that of Fokam et al. (2017) study in Yaounde, Cameroon, 
that reported a very low adherence level of 36% among adolescents on first line treatment. 
The observed lower adherence in Fokam and colleagues' study could be due to the fact that 
their study was carried out in a referral hospital in Yaounde. Most referral hospitals are 
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known to receive patients who are critically ill or need more specialised therapy. Hence it is 
possible to have such a low adherence given the participants could have been refereed from 
other health facilities from Yaounde and its environs. Furthermore, NGOs providing 
adherence support to adolescents and follow up in the communities had just started their 
projects between 2015 and 2016 and had not gained ground in much of the country. Some of 
these programs include the Catholic relief services, EGPAF and Adolescent Champions 
among others. 
Another contrasting result was observed in a study among Rwandan youths(Fawzi et 01., 
2016). The self-report adherence in that study was 63%. The authors of this study attributed 
the lower adherence rate to the high rate of psychological symptoms among this group of 
adolescents as a good proportion of them were already having signs of depression. In 
addition. Gross el oJ. (2015) reported a lower adherence of 61% among adolescents in 
Zimbabwe. 
The results are also in contrast with earlier findings in Western Kenya that showed an 
adherence of96% (Vreeman el 01 .• 2014). The observed higher adherence in that study could 
be because most of the participants were below age 14 years, hence maybe receiving support 
in the form of reminders from their parents/guardians to take medications. Another study in 
Uganda reported a high level of adherence in adolescents with a rate of 90.4% (Nabukeera-
Barungi el al., 2015). According to the authors of this study, the higher adherence might have 
been because the adherence rate reported in hospital records, which was used for the study 
could have been over estimated as some of the health workers might not have been in position 
to accurately estimate adherence by counting pills. 
Adherence was also measured through the Medication Possession Ratio (MPR) and the 
results were lower than the self-report measure. The difference between the two measures 
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was compared using the Kappa statistics. There was substantial agreement of 66% between 
the two measures. This suggests that the self-report and MPR method of measuring 
adherence is likely to yield similar results if used in the same population under same or 
similar context. Indeed. this study is one of the few studies to compare adherence 
measurements using self-report and MPR among adolescents and has shown some 
concordance between the two scales. Earlier studies have compared pill counts and viral load 
suppression (Martelli, Antonucci, Mukurasi, Zepherine, & Nl>stlinger, 2019). A study by 
Denison and others in 2015 had reported adherence using self-report and MPR but did not 
show the level of agreement between the two methods (Denison, Koole. et al., 2015). 
5.3 Determinants of adherence among adolescents 
A number of factors that significantly determined adolescents' adherence were analysed in 
this study. These adherence determinants are discussed in the section that follows. 
The determinants of adherence considered were demographic, socio-cultural and health 
facility related among others. From the bivariate analysis conducted, 12 variables were 
statistically associated with adherence but after adjustments at the multivariate analysis, 
only two variables - experiencing side effects and internalised stigma - remained 
statistically significant. 
From the results, a majority of the adolescents reported side effects as one of the reasons for 
failing to take medications and the relationship was significant. After adjusting for other 
variables, the relationship was still significant with the odds of adherence higher among 
adolescents who did not experience side effects. This might be because side effects that 
come with ARVs especially at the start of medications may be acute and may be a reason 
for failing to take medications. Indeed, the results here are consistent ....; th some earlier 
studies in Cameroon and Kenya in which medication related side effects were seen to affect 
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adherence (Fonsah et al., 2017; Wambugu et al., 2018). Mabunda and others however had 
contrasting findings as the authors showed that side effects had no association with 
adherence (Mabunda, Ngasama, Babalola, Zunza, & Nyasulu, 2019). 
The higher proportion of adolescents in this study who reported medication-related site 
effects is however not surprising given that most of the adolescents sampled in this study 
were on efavirenz based medications. These medications are associated with greater side 
effects such as nausea, vomiting, headaches, swelling of the face, skin rashes and 
colourations. Side effects, particularly those which exert physical changes to the body, 
become an issue as adolescents at their age are very concerned about their physical outlook. 
Therefore, they may consider skipping the medications to avoid such changes. 
The experience of internalised stigma also significantly predicted adherence at the 
multivariate level. Higher odds of non-adherence were observed among adolescents 
experiencing internalised stigma. Generally, experiences of internalized stigma leads to self-
imposed isolation and exclusion from social situations (Kalichman, 20l3). This may cause 
reduced self-efficacy and depressive symptoms such as disempowerment, helplessness, 
inability to concentrate, and feelings of negativity and anguish (Brouard & Wills, 2006) 
cited in (Turan el af., 2016). It is likely that these symptoms make HIV positive adolescents 
to adhere less to medications. These experiences may also cause depression which has been 
shown in some studies to predict poor adherence (Fonsah et al., 2017; Wambugu et al., 
2018). 
Furthermore, internalized stigma could also cause forgetfulness, which is a major challenge 
to adhering to medications. Although the relationship between adherence to ARV and 
internalized stigma has not been extensively studied especially among adolescents, there is 
a need to critically consider it given that the other factors like socio-demographic factors 
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and socio-cultural factors that have given been attention in literature, are in many cases, not 
significantly associated with adherence among adolescents. A few studies have however 
reported the relationship between internal stigma and adherence in other age groups. One of 
such is a study among HIV positive women in the United states, which showed a significant 
association between adherence and internalised stigma (Turan et al., 2016). 
A number of demographic characteristics were considered. In terms of age, adherence was 
seen to be highest among early adolescents (87.4%). This confirms findings from Barundi 
and others in Uganda that reported adherence among adolescents less than l5years to be 
89.6% (Nabukeera-Barungi et al., 2015). Adherence may be higher among these younger 
adolescents because they may be getting constant reminders from parents or guardians to 
take medications. This is probably an indication that transition to adult care is still not 
adequate hence the older adolescent who are gradually being transferred to adult care are 
still facing challenges to adhere to medications. 
Similar to some earlier studies across sub-Sahara Africa (Nyogea et ai., 2015; Dagli-
Hernandez et al., 2016; Mabunda et al., 2019), the relationship between age and adherence 
in this study was not significant however. A study carried out in Tanzania among 
adolescents also revealed comparable fmdings with age having no significant relationship 
with adherence (Martelli et al., 2019). However, some earlier studies had shown a 
significant relationship between age and adherence (Hudelson & Cluver, 2015). 
The difference in adherence between male and female adolescents was also considered. 
Adherence was higher in males even though the difference was not statistically significant. 
The observed higher adherence in male could be due to the gender roles where females are 
given more domestic task than the males and hence they can have higher chances of 
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forgetting to take medications when they are overwhelmed with other activities. This is 
similar to earlier studies (R. Gross et 01.,2015; Nabukeera-Barungi et 01.,2015; Xu, Munir. 
Kanabkaew, & Le Coeur, 2017) which showed that sex differences did not significantly 
affect adherence. However, a study by Wiens and others (2012) among Ugandan 
adolescents showed sex as having an effect on adherence, with adolescent males being more 
likely to adhere. 
With respect to level of education, adolescents with secondary education had a higher 
adherence compared to the others. This could probably be attributed to the fact that 
education broadens their understanding of the need for medications and hence are more 
likely to take their pills. These results are indeed not different from those of Denison et al. 
(2018) in Zambia in which they noted that little or no education was associated with poor 
adherence. This calls for increased support and more counselling among less educated 
adolescents, including the use of local languages for some of such adolescents. 
Also. adolescents who profess other forms of religion other than Christianity and Islam had 
lower adherence. Belonging to a Christian or Muslim religion probably allows adolescents 
the chance to believe in God and a hope for a life ahead which entreats them to adhere and 
live on. Some religious houses also offer spiritual counselling, which could reduce possible 
depression - a major barrier to adherence. 
Moreover, adolescents living with parents or guardians also showed higher adherence 
compared to those living alone. These results are in concordance with those of William and 
others that showed that living alone was associated with poor adherence (Williams et 01., 
2006). This is not surprising because guardians/parents are more likely to give constant 
support and reminders to such adolescents to take their medications and offer moral support. 
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This is indeed consistent with findings by Kim and others in the United States where 
adolescents reported that their parent/guardian reminded them to take medications and this 
helped to improve adherence (Sung-Hee et al., 2014). Adolescents who leave alone may 
also face other challenges, for example, providing for themselves. Together with other 
difficulties that come with adolescence, this situation could force such adolescents to be less 
adherent. 
In a nutshell, the results of this study showed that although there were important differences 
in adherence along the different socio-demographic background characteristics of 
respondents, none of the demographic factors significantly predicted adherence among 
adolescents. A cross-sectional study in Kenya had reported similar findings (Wambugu et 
al., 20 18). This is surprising given that these variables were conceptually thought to 
detemline adherence. However. it is a probable indication that the factors that affect 
adherence among adolescents are perhaps more than the socio-demographic characteristics 
that differentiate them. 
Health service factors that were assessed included long waiting time in the health facility 
and poor attitude of hospital staff to adolescents during clinic visits. Adolescents who 
reported that they experienced long waiting time had a lower adherence. However, it 
surprisingly did not influence adherence in the final analysis. A meta-analysis study showed 
that long waiting time in hospital is linked to poor adherence (Croome, Ahluwalia, Hughes, 
& Abas. 2017). A similar study in Kenyan equally noted a significant relationship between 
waiting time and adherence among adolescents (Wambugu et al., 2018). This could be 
linked to the fact that waiting to receive care during clinic visits discourages some of them 
from keeping their hospital appointments and possibly missing refills. Long waiting times 
in some health facilities in a study in Cameroon has been attributed to limited staff with 
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many adolescents to attend to. There is therefore a need for more staff trained in adolescent 
care so that this could shorten waiting time. Also, the adolescents could be sub-divided into 
different groups so that there are fewer adolescents at each visit. This could help reduce 
waiting times especially in facilities where there are a good number of adolescents on 
treatment. 
Poor attitude of hospital staff also affected adherence, although the relationship was not 
statistically significant. Adolescents who had experienced poor attitudes from hospital staff 
had a significantly lower adherence. Perceived poor attitude of staff could have resulted 
from the manner of communication or reaction towards adolescents. This could lead to lack 
of trust in healthcare providers. Adolescents, especially those with HIV, need more special 
attention given the psychological stress which they go through. They need trained providers 
to adequately support in their care. Therefore, facing more difficulties with attitude from 
staff simply adds to their challenges and can lead to defaulting hospital appointments and 
refills. 
The use of traditional medicines, religious beliefs and the belief that drugs were no longer 
needed are socio-cultural factors considered in this study. Adolescents who noted that they 
had been using traditional medicines had a lower adherence compared to those who did not 
use traditional medicine. Nevertheless, the relationship was not statistically significant in 
the final analysis. This is surprising because the use of traditional medicines in most cases 
substitutes the use of ARVs as shown in previous research. For example, one study found 
that using traditional medicines was one of the factors undermining ARV adherence as the 
patients were secretly consuming the drugs in place of ARVs (Croome et al., 2017). 
Similarly. Thielman and his team in Tanzania observed a drop in adherence level among 
patients who were visiting traditional healers (Thielman et aJ., 2014). They further noted 
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that treatment fatigue was one factor that was causing patients to seek alternative forms of 
medication. However, Gross and others in Zimbabwe had contrasting results, showing that 
the use of traditional medicines did not have a relationship with adherence (Robert Gross et 
01 .• 2015). Lubinga et al 2012 also had similar fmdings in Uganda, where the use of 
traditional medicines had no significant relationship with adherence (Lubinga, Kintu, 
Atuhaire, & Asiimwe, 2012). 
Moreover, these traditional medicines are even used without the knowledge of the 
healthcare provider and some of them might have antagonistic properties or molecules that 
could interact with the ARVs. The use of traditional medicines might not have been 
significant but its use alongside the ARVs by patients should be discouraged. This is because 
its effect on adherence in this study might have been masked by other factors such as 
treatment fatigue. This is so because 82% of those who were taking traditional medicines 
also indicated that they were tired of taking medications. Therefore, adolescents on 
treatment and their guardians need to receive constant reminders on the implications of 
taking traditional medicines over ARVs . 
.\ Iso. the perception that there was no need for drugs anymore was also investigated. The 
participants who felt there was no need for drugs were less adherent. This could be so 
because some adolescents who were experiencing side effects felt they did not need drugs 
anymore. The adolescents who had taken drugs and were feeling better also had the same 
feeling and this was causing them to neglect their drugs. 
This study considered the following patient factors: medication related side effects, 
internalized stigma, lost pills, busy, other illness, waking up early and not understanding 
treatment regimen. Medication related side effects and stigma have been discussed above. 
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A number of participants indicated that the lost their pills, and the results showed that losing 
pills affected adherence, albeit the relationship was not statistically significant. Pills can get 
missing in cases where they are hiding them to ensure privacy. Furthermore, given that 
some of these adolescents are currently internally displaced as a result of the current socio-
political crisis in the English-speaking regions of Cameroon (where the study was carried 
out), they can equally loss their pills as the refuge places may not allow them the privacy 
and safety of their medications. 
Some adolescents also pointed out that they were busy, and this negatively affected 
adherence. These adolescents could be busy with their daily routines such as schooling, 
working and carrying out other activities which can get them distracted from taking 
medications or cause them forget taking the medications. Further analysis showed that most 
of the adolescents who were leaving alone were also busy and this could possibly be 
undermining their ability to adhere to medications. This is in line with previous research 
where being busy was causing adolescents to adhere less to treatment (H. Kim et al., 2017). 
Another important factor that was considered was the presence of other illnesses. This factor 
also adversely affected adherence, with sick adolescents reporting lower adherence to 
treatment. This variable however did not significantly determine adherence after adjusting 
for confounders and it was surprising because being ill increases the burden of medications 
and gives room for excuses not to take ARVs. Some of the adolescents went further to 
indicate that illnesses that cause them to vomit prevent them from taking their pills. These 
findings were related to those from a study in Yaounde which revealed that adolescents with 
comorbid conditions had higher odds of non-adherence (Fo nsah et al., 2017). 
In addition, failing to understand the treatment regimen was also a factor which was shown 
to significantly affect adherence at the bivariate analysis. The study sampled only 
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adolescents who were aware of their status; however, many of them did not understand why 
they had to take drugs daily and probably for a life time. Further analysis showed that 56% 
of the adolescents did not even know the name of the drug they were taking and 6% of these 
adolescents reported that the ARV drugs were not making them healthy. Hence, health 
service staff and counsellors have a role to always make sure that adolescents know their 
medications and have a comprehensive understanding of why it is necessary to take them. 
These results were in line with those of Denison et a1. (2015) where adolescents were 
reported to be less adherent because they did not understand the medication (Denison, 
Koole. et al., 2015). Failing to understand the regimen was hence presenting some mental 
issues to deal with and could possibly contribute to the lower adherence observed. 
Aside the patient factors, external stigma was also another possible factor considered that 
could affect adherence in this study. The link between stigma and adherence was observed 
to be statistically significant. A good number of adolescents had faced some form of external 
stigma because they were HIV positive. It occurs in the home, school, and from media. 
When adolescents are faced with stigma from those people around them like family who are 
aware of their status, it becomes more devastating given that they rather wish for support 
and encouragement. This calls for need for more sensitizations on parents/guardians of HI V 
infected parents on the consequences of stigma on the children. Beyond these parents, this 
sensitization against stigma should be extended to the general public and media where 
people can be educated to avoid negative talk and adverts about HIV / AIDS. This results are 
similar to earlier findings of Wambugu and others in which adolescents who were 
stigmatised were less adherent to treatment (Wambugu et af., 2018). 
Furthermore, being away from home was shown to reduce adherence. This is most likely so 
because there is the possibility to forget pills when leaving home or the conditions of the 
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new environment might not be conducive enough to take pills. A study in Kenya had 
contrasting results as being away from home had no significant association with adherence 
(Talam, Gatongi, Rotich, & Kimaiyo, 2008). Additionally, running out of pills also had a 
significant association as adolescents who reported losing pills were less adherent. An 
earlier study in Ethiopia showed that running out of pills affected adherence (Tsega, 
Srikanth, & Shewamene, 2015). 
In conclusion. the conceptual framework was designed indicating that the determinants of 
adherence ranged from demographic, socio cultural, patient factors and other factors. The 
results showed that the factors that determined adherence among adolescents was more than 
the demographic and socio-cultural factors that differentiate them. Internalised stigma and 
medication related side effects were the factors that significantly determined adherence. 
5.4 Challenges of Adherence in adolescents 
The challenges to adherence among adolescents were examined. Participants reported a 
number of challenges related to taking prescribed medications as well as keeping 
appointments. The most reported challenge to adherence was stigma (externalised). This 
stigma is experienced beginning from home, to school and sometimes even in health 
facilities. Some of the adolescents reported they were not allowed at home to play, eat or 
sleep on the same bed with their peers. Some also indicated they faced overt discrimination 
at home. These kind of behaviours towards adolescents could easily cause depression and 
other psychological issues which could cause them not to take pills. Stigma as a barrier to 
adherence in adolescents has been reported in a number of studies (Kunapareddy et al., 
2014; Lawan, Amoie, Jahun, & Abute, 2015; Abubakar et al., 2016; Croome el aI., 2017) 
(Shubber et al., 2016; Ammon, Mason, & Corkery, 2018). Stigma is still pervasive in HIV 
care and comes from varied sources. Given the adverse consequences of stigma on HIV 
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positive adolescent's health, it is imperative to include campaigns against stigma in HIV 
programmes since earlier focus has always been on prevention, screening and treatment. 
One other major challenge faced by adolescents was forgetfulness to take medication. 
Earlier studies have also revealed forgetfulness as a barrier to adherence (Kunapareddy et 
aI., 2014; Sung-Hee et al., 2015; Ankrah et a!., 2016; Croome et al., 2017; Wambugu el ai., 
201S). Medications could be easily forgotten because adolescents may be busy, do not have 
reminders or support systems to remind them to take their medications or they may simply 
have travelled without the medications. For younger adolescents, guardians still have the 
duty to remind them daily to take medications. However, for the older adolescents, setting 
alarms as reminders and some random prompts from the guardian could also solve this 
problem of forgetfulness. Medication taking could also be associated with some daily task 
like tooth brushing so that the adolescent gets a self-conscious reminder to take medication 
once they are brushing their teeth. 
Being in school was also making it difficult to take medications. Indeed, a study by 
Abubakar and others in Kenya revealed that attending school affected adherence level 
among adolescence (Abubakar et al., 2016). Schooling causes adolescents to wake up early, 
and might not create time to take their medications. This could be worse for adolescents 
living in boarding schools as lack of secrecy may also hinder taking medications effectively. 
In these situations, the health staff could work together with the adolescent to find a 
convenient time for taking medications. For example, for an adolescent who wakes very 
early for school, the medication time could be adjusted and taken in the evening. 
Adolescents also noted that they were tired of taking medications. This is consistent with 
similar earlier studies around Sub-Saharan Africa (Kunapareddy et al., 2014; Maskew et al., 
2016; H. Kim et al., 2017; Galea el al., 2018). These earlier studies have noted that the daily 
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uptake of drugs causes fatigue and therefore makes it challenging to adhere to treatment 
effectively. This treatment fatigue might be commonplace among adolescents who are 
perinatally infected and have been on drugs for a long time. This also discourages them from 
taking their drugs. Treatment fatigue has been shown to affect even adults who are on ARV s. 
For adolescents, some colour changes on the drug containers could give a sense of attraction 
which might re-awaken the zeal for medications. 
The current political crisis in Cameroon was also one of the major barriers. A number of 
adolescents are unable to keep their hospital appointments and sometimes run out of pills. 
Some of them are internally displaced and are struggling to adapt to the new environment. 
A few of them complained of lack of food and other social amenities, which complement 
taking of medications. There is therefore the urgent need for the Cameroon government 
together in collaboration with the stakeholders involved in the current political crisis to bring 
it to an end. 
Furthermore, financial constraints were a challenge for a number of adolescents. Lack of 
money affects food availability, housing situation and transportation to hospital. 
Consequently, some of them are unable to attend all hospital appointments and are unable 
to refill their drugs. Some health facilities through NOOs make provision for snacks to 
adolescents during clinic visits in order to improve on attendance. However, this is not 
enough and there is still need for more aid to adolescents on ARV treatment as well as 
schemes to empower some of the parents to adequately cater for them. Some earlier studies 
have also reported that food insecurity as a barrier to adherence (Coetzee, Kagee, & Bland, 
2015; Abubakar et aI., 2016) 
Finally, ill health and other co-morbidities like Tuberculosis (TB) were impediments to 
adherence and about one-third of the participants pointed out that when they are sick it 
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affects their ability to take drugs. Some of the adolescents were on TB treatment in addition 
to the ARY drugs. This adds to the burden of daily pills. Some studies have also reported 
co-morbidities as barriers to adherence (Croome el al., 2017; Fonsah el al., 2017). 
Adolescents with such co-morbid conditions might need extra encouragement from 
parents/guardian and health staff to sustain more medications as most of these co-morbid 
conditions do not last for long. 
5.5 Adolescent's perspective on adherence 
Most of the adolescents had a good understanding of adherence to antiretroviral therapy. 
This was seen in their response in which adherence meant taking medications. This implies 
that adolescents have received some counselling and advice about medications from the 
health care givers. This information is important as having a simple understanding of what 
adherence is could also help them improve on their adherence. This was also confirmed in 
a further analysis where 70% of the adolescents who had a proper understand of adherence 
were adherent to treatment. 
The results also revealed that many of the adolescents were taking the medications correctly 
because it made them healthy. This understanding also made them more adherent. 
Furthermore, a good number of them also indicated taking medications for family. This also 
goes to support the role of family in adherence which has been shown by some authors. For 
example, Beals el al. examined the role played by older wives and mothers in promoting 
adher<!nce to HIY medication among HIY -infected person in general and husbands and older 
sons in particular (Beals et al., 2006). In this study, caregivers are understood to be important 
in the patients' treatment adherence as they constantly remind them to take medications and 
to attend clinics as well. Other roles observed to have been played by caregivers in this study 
are; reporting about strong attitudes regarding medication hassles, concerns over treatment 
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failure and general concerns about patient's adherence to treatment. These are factors which 
could affect especially adolescents staying adherent on treatment. 
Additionally, in some other contexts where HIV stigma is still rife, family members of HIV 
infected children and adolescents also face some stigma and hence they are largely involved 
in dealing with stigma as a way of supporting and encouraging especially the younger ones 
to stay adherent. McHenry et al. . provided perspectives from Kenyan Child caregivers and 
adolescents Living with HIV in relation to HIV stigma(McHenry et al., 2017). The study 
report the negative and inaccurate views about HIV held by community members, including 
associating it with immorality and believing in transmission by casual interactions. 
The results also showed that most of the adolescents were determined to take their 
medications. However. only 55% were ready to take medications if their privacy was not 
ensured. This is probably because the lack of privacy gives room for uncomfortable 
questions from people around which they will not want to answer. This further confirms the 
effect of stigma on medication adherence, as adolescents on treatment will not want more 
people finding out about their status to avoid stigma. A study by Rao and others in 2007 
reported that. the fear of taking drugs in the presence of family and friends who were not 
aware of one's HIV status was a hindrance to adherence as patient will rather skip taking 
the medication to avoid rejection. 
The adolescents further asked questions regarding their treatment. The most asked questions 
were related to changing the fonn of treatment and the frequency of treatment. These two 
were related because changing the form to injectables for example as suggested by some 
could reduce the frequency of medication. These questions also reflect the issue of pill 
burden which was reported as a determinant of adherence to treatment medication and which 
had a significant relationship at the bivariate analysis. Furthermore, as a strategy to improve 
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adherence, 64% of the adolescents had suggested a reduction in pill burden. A study by 
Bangsberg and others in 2010 associated high pill burden with lower adherence Bangsberg 
(Bangsberg & Deeks, 2010). 
5.6 Improving adherence among adolescents 
Adolescents with HIV have been shown earlier to encounter a number of adherence 
challenges. Therefore, participants made suggestions to help improve adherence. From the 
results, about two thirds of the adolescents believed reducing the frequency of medication 
could help improve adherence. They went further to propose the use of other forms like 
injections which could last for a month and hence reduce frequency of taking medications. 
Changing the form of medication is complicated and may go beyond the ability of the health 
facility and perhaps the country. It is dependent largely on trends and discoveries made in 
healthcare. For HIV, there are on-going trials for injections that could last for at least a 
month and reduce the daily task of taking medications. One of such is the Taiwan based 
United Biopharma trial which, if successful, could be a way to go. Indeed, Ahmed and his 
team have shown in their study that a reduction in pill burden could enhance adherence 
(Ahmed. Farooqui. Syed Sulaiman, Hassali, & Lee, 2018). 
Additionally, many of these adolescents agreed that the use of reminder messages could also 
help improve adherence. This could be a way to improve on adherence given that 
forgetfulness to take medications was one of the major barriers. Moreover, mobile phones 
are widely used, and the health system could make use of its availability to help adolescents 
improve on adherence since many of the parents/guardians can have access to a phone. 
Using SMS reminders is possible and further research could consider investigating its 
feasibility among adolescents. Similar findings were also noted from previous reviews 
where reminder messages were one of the most reported facilitators of adherence among 
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adolescents (Reisner et al., 2009; Denison, Banda. et al., 2015; Sung-Hee et aI., 2015; 
Nabukeera-Barungi et ai., 2015; Croome et al., 2017) 
The attitude of staff to adolescents could also be a way to improve adherence. About 70% 
of the adolescents indicated that staff could be friendlier to them to improve adherence. 
There is therefore a need for facilities to have well trained staff in adolescent care who can 
listen and comprehend adolescents and their challenges and counsel properly. Workload 
reduction for staff in some cases could make them more accommodating and hence offer 
more time for counselling the adolescents. Additionally, refresher courses to update staff on 
current trends in HIV care for adolescents could also help improve on their model of care. 
Previous studies have indeed revealed that caring health workers could also support 
adherence (Wasti et ai., 2012; Nabukeera-Barungi et ai., 2015). A study among Ghanaian 
adolescents also suggested that adequate staff support was a facilitator of adherence 
(Ankrah el ai., 2016). Furthermore, few of the participants pointed out that medications 
should be brought home. This was not a popular opinion probably because having health 
staff come home might call for the need to respond to unpleasant questions from family 
members of neighbours. 
Finally, there were other issues like care giver support, providing food and financial 
assistance, advise and encouragement, having an alarm, having their doubts clarified, 
showing love, changing taste and size of tablet, reducing stigma and family support that 
were raised as other factors that could improve on adherence. Access to food as a facilitator 
of adherence had also been reported in some earlier studies (Nabukeera-Barungi et al., 20 15; 
Croome et al., 2017). A study by Kim and others also reported reduction of stigma as a 
possible means to promote adherence(Sung-Hee et ai., 2014). Likewise, care giver support 
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and encouragement has been shown to promote adherence to ARV among adolescents 
(Wasti et al., 2012; Denison, Koole, et al., 2015; Ankrah et al., 2016; Ammon e/ al., 2018). 
In summary, findings from the study and evidence from other studies have shown that a 
number of factors could improve adherence among adolescents. Using medication 
reminders, improving staff attitude and offering attractive incentives at health facilities 
could promote adherence, especially if used in synergy. 
5.7 Treatment outcomes among adolescents with "IV 
The treatment outcomes examined in this study were viral load suppression, CD4 counts 
and retention rates. For viral load suppression, 70% of the adolescents had a suppressed 
viral load. This result is slightly lower than those of Chhim and others in Cambodia where 
a viral load suppression of77% was reported among adolescents (Chhim et al., 2018). The 
findings however. were higher than the 63% reported in a study in the Mwanza region in 
Tanzania (Martelli et al., 2019). Taken together, the results from the current and previous 
studies indicate that a good number of adolescents are still unable to have their viral loads 
drop below the limit of detection as most of the result falls short of the UNAIDS 90-90-90 
targets of having 90% viral load suppression among people receiving ARVs. This could be 
attributed to the challenges associated with taking the ARVs. Some of them could also have 
developed treatment failure and become resistant to the ARVs. This is reflected in some of 
them being switched to second line regimen. 
Further analysis showed that, only 61 % of the adolescents who were adherent had 
suppressed viral load. Although this discrepancy was noticed, this confirms the trend that 
adherence to ARV treatment is a main predictor ARV adherence as two thirds of the 
adherent adolescents showed viral suppression. This result was also in line with those of 
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Chikwari in Zimbabwe that reported viral load suppression of 63% among adherent 
adolescents (Chikwari, Ferrand, & Simms, 2017). 
There were also 9% of adolescents who were non-adherent but had suppressed viral loads. 
It has been suggested that this kind of discrepancy is also possible because even in the case 
of resistance. ARV drugs regimens still exert some degree of anti-HIV activity on the 
resistant virus (Bangsberg & Deeks, 2002). Furthermore, adherence levels between 50% 
to 100% can achieve viral load suppression when using non-nucleoside reverse-
transcriptase-inhibitors(NNRTIs) regimens (Bangsberg, 2006). Examples of NNRTls 
molecules include abacavir, lamivudine and tenofovir to name a few, some of which are 
used by adolescents in this study. 
Findings from the study also revealed that 22% of adolescents who were adherent to 
treatment had unsuppressed viral loads. This is counter intuitive as the expectation is that, 
being adherent should lead to viral load suppression. This could probably be attributed to 
unnoticed resistance to treatment or the fact that some of the adolescents might have over 
reported self-report adherence (Cruz et al., 2014). This is an indication that adherence 
reports in health settings should be complimented by laboratory markers like viral load to 
reduce possibilities of unnoticed resistance to treatment which could gradually aggravate to 
AIDS. 
In the case of CD4 counts, 89% of the adolescents had counts above 200cells/ul. These 
findings imply that majority of the adolescents had good CD4 counts and it was even shown 
that the counts gradually increased over time. CD4 count were also compared with 
adherence, and 69% of adherent adolescents had CD4 counts above 200ceIls/ul. However, 
the observed difference in CD4 counts probably occurred by chance as it was not significant. 
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These results perhaps could be used to further buttress the point that being adherent 
increases the likelihood of improving on CD4 counts. 
Retention rates were taken at 6, 12 and 24 months for the cohort of adolescents who were 
enrolled into treatment between January and December 2015. Retention rates were highest 
at six months (88%) and were shown to decline by 24months (58%) which was expected 
due to the continuous L TFU cases and deaths. The 6 months retention was lower than that 
from a study in Zimbabwe that reported a 6months retention of 92% (Matyanga et 01.,2016). 
The 12months retention rate was also lower than the 12 months retention of 96% reported 
in a Ugandan study (lzudi et 01.,2018). As for the 24 months retention, it was lower than 
the 82% reported by Matyanga and others in Zimbabwe (Matyanga et 01., 2016). This 
difference could be because of the continuous lost to follow cases which was highest at the 
Shisong General Hospital. This high LT FU cases recorded could be attributed to the political 
crisis that has led to school shut down in these areas for almost three years and hence many 
of the children have left to other regions to have access to school. 
5.8 Facility preparedness towards care of adolescents 
One of the specific objectives of this study was to access the readiness of health facilities to 
receive and offer HIV care to adolescents. The findings revealed that 7 out of the 9 health 
facilities were already at stage 5 based on the JSI tool that was used. This implies that these 
facilities were already ready to receive adolescents into care and needed maintenance and 
support. This was probably so because these facilities have been providing care generally 
for long and hence it was easier to incorporate adolescent services. Two of the health 
facilities, the Nkwen Baptist Hospital in Bamenda and the Limbe Regional Hospital, were 
however at stage 4, which is the stage of action. Both health facilities had limited staff 
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trained in adolescent care and their laboratories were not adequately equipped for associate 
tests which they currently still refer patients to other facilities to carry out. 
5.9 Strengths and contribution of the Study to knowledge 
Adherence and treatment outcomes of adolescents living with HlV remain interesting as 
HIV continues to be a major public health concern. Within this premise, assessing the 
determinants of these outcomes has been the goal which this study worked to achieve. The 
strengths of this study are therefore viewed from the following perspectives. 
1. This study is one of the first detailed studies in Cameroon in general and 
Anglophone Cameroon that has assessed adherence among adolescents and 
treatment outcomes. Earlier studies have assessed adherence in adults and the few 
studies among adolescents have been in French speaking Cameroon. The study has 
added to the available literature on the level of adherence among adolescents in this 
part of Cameroon. It has also provided additional knowledge on the level of 
treatment outcomes among adolescents which has been non-existing for the North 
West and South West regions of Cameroon. 
2. The results of the study have also given a deeper insight into the determinants of 
adherence to ARVS and the challenges faced by adolescents living with HIV. The 
study revealed experiencing medication related side effects and internalised stigma 
as the major determining factors of adherence. This is a major contribution to 
knowledge in this domain and opens new opportunities for more research to fully 
understand the range of factors (especially the psychological factors) affecting 
adherence to AR V among adolescents in Africa. 
3. Furthermore, adherence was measured using both self-report and medication 
possession ratio. The two methods were subjected to a comparison and there was 
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substantial agreement between the scales. Earlier studies had compared self-report 
and other measures but not the medication possession ration. The study is hence one 
of the few studies to show that adherence measures using either self-report or MPR 
may give similar results. 
5.1 0 Limitations ofthe study 
While the study has several strengths, there are a number of limitations. These limitations 
are discussed below. 
1. The self-report method for measuring adherence was used in this study. Therefore, 
there was the possibility of participants overestimating adherence. However, there 
was significant agreement between the self-report measure and the medication 
possession ratio, which suggests that the issue of overestimation may have been 
minimised. 
2. The design of the study is largely cross-sectional; hence the relationships which have 
been shown in the results should be interpreted as statistical associations and not 
causal associations. 
3. In addition, a high non-response rate was noticed for a number of variables, up to 
30% in some cases. This could potentially affect the overall power of the study. 
However, this was not necessarily the case because, coincidentally, a non-response 
rate of 30% was earlier assumed for the study to give it more power. 
4. Finally, the JSI tool used to assess facility preparedness was adapted for use in this 
study. Given that it was developed and tested in contexts other than in the Cameroon 
health system, it might not fully apply in the context. However, the tool is 
standardised and has been used to assess facilities in many countries of Africa, Asia 
and the Europe. 
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5.11 Chapter summary 
Chapter 5 has given a detailed discussion of the results that were presented in chapter four. 
The discussions highlight important determinants and challenges of adherence which have 
implications for policy, practice and research. In the next chapter, specific conclusions are 
drawn, and recommendations made to address some of the challenges identified. 
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CHAPTER SIX 
CONCLUSION 
6.1 Conclusions 
This study assessed the determinants of adherenc~ to ART treatment among adolescents 
enrolled on treatment. Findings suggested majority of the adolescents were adherent to 
treatment and these results were different from those of an earlier study in Cameroon that 
reported a lower adherence. 
From the results and accompanying discussion, it could be concluded that the socio-
demographic and socio-cultural factors that differentiate adolescents who are HIV positive 
do not necessarily undermine their ability to adhere to treatment. Rather, the factors that 
affected adherence among adolescents in the context of this study are more psychological 
(internalised stigma) and medication related side effects. 
One of the major challenges of treatment adherence was stigma which the adolescents face 
from home, school, media and sometimes health service staff. Another challenge of 
adherence was forgetfulness to take medication and then the use of reminders to improve 
adherence was a major suggestion to improve adherence. It is likely that implementation of 
a reminder system for adolescents together with other factors like improvement in the 
attitude of staff can be a way to scale-up on adherence among adolescents in Cameroon. 
Furthermore, reviewed literature revealed that adherence measurement was complex as 
there is no standardised method of measurement. The study measured adherence through 
self-report and the Medication Possession Ratio. Adherence from the self-report measure 
was higher than from MPR, but there was substantial agreement between the scales. 
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Perhaps this might mean that measuring adherence through self-report or MPR could give 
similar fmdings. 
With regard to the ARV treatment outcome of adolescents, findings from the study showed 
that over two thirds of the adolescents had suppressed viral loads. Further analysis indicated 
that there were some adolescents who were adherent but with unsuppressed viral loads and 
his could indicate the probability of unnoticed drug resistance or adherence being over-
reported. This finding suggests the need to complement self-report and pharmacy refill 
adherence measurements with laboratory test results like viral loads. 
Finally, it was observed that most of the selected health facilities were ready to receive 
adolescents with HIY and needed support, maintenance and expansion. This support could 
be in form of trainings, infrastructure and motivations to enable these facilities to maintain 
and expand their services. 
6.2 Recommendations 
Based on the results of this study, the following recommendations have been made. 
1. Recommendations for policy makers 
• The Ministry of public Health of Cameroon should include a procedure to identify 
and follow up cases of adolescents experiencing internalised stigma in its national 
guidelines for treatment adolescents living with HIY. The adolescents can be 
assessed for internalised stigma as part of the routine counselling sessions which 
they receive during their clinic visits. 
• The Ministry of Public Health of Cameroon and other stakeholders involved in HIY 
should include campaigns against ail forms ofHIV related stigma from individuals, 
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schools, health facilities and the media. These can be done together with other 
campaigns done for HIV prevention and screening as they reach out to people in 
the communities. 
The Ministry of Public Health of Cameroon should continue to support health 
facilities receiving adolescents by providing more trainings, infrastructure and 
motivations to enable health facilities provide the necessary care to ALHIV. 
2. Recommendations for health care practitioners 
Adherence monitoring should not be limited to self-report measures or pharmacy 
records. Laboratory markers like viral load tests should be done from time to time 
to compliment the other measures 
Furthermore, adolescents had reported forgetfulness as a major challenge to 
adherence. Hence health care practitioners could adjust medication times to some 
daily activities like tooth brushing which could help them remember to take their 
pills. 
Health workers should be more accommodating and friendlier to the adolescents. 
They should offer more time for psychosocial support and counselling. This will 
help improve retention rates, adherence and hence viral load suppression. The 
workers could be motivated to be friendlier by rewarding performing staff and also 
laying sanctions to staff who exhibit poor attitudes towards the adolescents. 
3. Recommendations for future research 
In conducting this study, a number of research gaps were identified which could not be filled 
as they were not part of the objectives of the study. In this respect, the study puts forth the 
following suggestions that future researches could take up. 
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Given that forgetfulness to take medications was a major challenge to adherence, 
adolescents suggested the use of reminder messages to reduce forgetfulness. The 
study therefore recommends that an intervention study be done to ascertain if the use 
of reminder messages through phone could improve adherence among adolescents in 
Cameroon. 
A further study could also be done using qualitative methods like focused group 
discussions and in-depth interviews to allow adolescents the opportunity to share their 
experiences with more details that could also help inform decision making or policy 
formulation about them. 
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APPENDICES 
Appendix I! Invitation to Participate in PhD Research 
Dear Potential Participant, 
I am Mbuwir Charlotte Bongfen, PhD student in the Department of Public Health at the 
University Ghana, School of Public Health. I would like to invite you to participate in a 
research project I am conducting on Determinants of Adherence and Treatment 
Outcomes among Adolescents Living with HIV in Cameroon. Please fmd attached 
detailed infonnation about the proposed research and what your role as a participant will be. 
Your participation is not compulsory but it will help in a bid to improve the care delivered to 
Adolescents living with HIV in Cameroon. If you accept to participate, I am grateful you. If 
you do not accept to be a part of the study, it will not affect you in any way. 
Thank you 
11.-
Mbuwir Charlotte Bongfen 
202 
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Appendix 2: Participant Information Sheet for adolescents at least 18years 
Please read the following information carefully. It will help you decide whether or not to 
participate in the research. You can take enough time to think about your participation and 
ask any further questions if there is need to do so. 
Wby have you been invited? You have been invited to be participate in this study because 
you receive Antiretroviral Treatment (ART) in this hospital. Please read the foml and and 
ask questions to clarify any doubts before accepting to be part of the study. 
What is the aim of the research? The aim of this research is to find the factors that 
determine adherence to ART in Cameroon and the outcomes of treatment among 
adolescents with HIV. 
How are you going to participate? If you accept to take part, then your participation in the 
research starts signing the consent form of acceptance. You will also be have to answer 
some questions on a questionnaire on some factors that may affect adherence. 
How long will the study last? The data collection will last for a period of three months, 
that is. from June to August. During this time we will interview you just one time to fill the 
questionnaire and this will last for about 10 minutes. 
What are the risks involved? We are going to take some of your time especially when we 
shall interview you. However, you can choose not to answer any question if you are 
uncomfortable with it. 
Possible Benefits: You will have any physical rewards for being a part of this study and the 
care you will be given during your stay in the hospital will not depend on your participation 
in the study. However your participation in the study will help us to understand the 
determinants of adherence and make possible recommendations to stake holders on how to 
improve on adherence in adolescents. 
Confidentiality: All the information you will provide in the questionnaire will not be 
disclosed to anyone and will be used only for the purpose of this study. No names will be 
taken on the questionnaire, only numbers will be used. The information will be kept in our 
data base, coded and will not be used for any other purpose. The code will only be known 
by the researcher. The collected data will only be accessible to the researcher and 
supervisors. 
Right to withdraw: Taking part in the study is voluntary. After you have accepted to be 
part of the study, you have the right to withdraw at any time if you want to. It will also not 
be compUlsory for you to explain why you have decided to withdraw from the study if you 
decide to leave. 
Contacts: You can call the principal investigator in case of further inquiries through; 
Mbuwir Charlotte: 674 08 55 56. 
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Appendix J: Written consent form for Adolescents at least lSye8r5 
Title of Thesis project 
DETERMINANTS OF ADHERENCE AND TREATMENT OUTCOMES AMONG 
ADOLESCENTS LIVING WITH mv IN CAMEROON 
PARTICIPANT'S STATEMENTS OF CONSENT 
If you have decided to participate in the study, please sign or thumb print in the space 
provided below: 
By participating in this study, you I agreed that, 
I have been informed of the objectives and processes involved in this study. I also believe 
that I understand what is expected of me in this study. 
I understand how the data will be collected, what it will be used for and to whom it may 
be disclosed to. 
I was given the opportunity to ask questions and all my doubts were clarified 
I know that my participation is voluntary and I can decide to withdraw any time I choose 
as well as refuse to answer any question uncomfortable to me 
I hereby agree to participate in this study. 
Participant's signature/thumbprint: _________  
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Appendix 4: Information sheet for Guardian 
Dear Guardian/Parent, your daughter/son has been invited to participate in this research. 
Please read the information and then you can decide whether he/she should participate in 
this research. 
Why has he/she been invited? Shelhe has been invited to be part of this study because 
he/she came to this hospital for Anti-retroviral therapy. Please read the form carefully and 
ask any questions to clarify you before accepting for your child to be part of the study. 
What is the aim of the research? The aim of this research is to lind the factors that 
determine adherence to ART in Cameroon and the outcomes of treatment among 
adolescents with HIV. 
How is he/she going to participate? If you accept for himlher to take part, then her 
participation in the research starts when you sign the consent form of acceptance. He/she 
will also assent to participate in the study. He/she will then be required to answer some 
questions on some factors that may affect adherence. 
How long will the study last? The research will last for a period of three months, that is, 
from June to August. During this time we will interview himlher just one time to fill the 
questionnaire and this will last for about 10 minutes. 
What are the risks involved? We are going to take some of hislher time when we shall 
interview himlher. However, he/she will have the right not to answer any question ifhe/she 
is not uncomfortable with it. 
PO'i'iible Benefits: He/ She will not receive any direct benefits from participating in this 
study and the care you will be given during your stay in the hospital will not depend on your 
participation in the study. However your participation in the study will help us to understand 
the determinants of adherence and make possible recommendations to stake holders on how 
to improve on adherence in adolescents. 
Confidentiality: Any information he/she will provide in the questionnaire will be kept in 
secret and will be used only for the purpose of this study. No names will be taken on the 
questionnaire, only numbers will be used. The information will be kept in our data base, 
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coded and will not be used for any other purpose again. The code will only be known by the 
researcher. 
Right to withdraw: Taking part in the study is voluntary. After he/she has accepted to be 
part of the study, he/she has the right to withdraw at any time ifhe/she wants to. It will also 
not be compUlsory for himlher to explain why he/she has decided to withdraw from the 
study ifhe/she decides to leave. 
Contacts: You can call the principal investigator in case offurther inquiries through; 
Mbuwir Charlotte: 674 08 55 56. 
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Appendix S: Written Consent form for Guardian 
Title of thesis project 
DETERMINANTS OF ADHERENCE AND TREATMENT OUTCOMES AMONG 
ADOLESCENTS LIVING WITH HlV IN CAMEROON 
If you have decided that your son/daughter should participate in the study, please sign or 
thumb print in the space provided below: 
...................................................................................................... 
By participating in this study, you I agreed that, 
I have been infonned of the objectives and processes involved in this study. I also believe 
that I understand what is expected of me in this study. 
I understand how the data will be collected, what it will be used for and to whom it may 
be disclosed to. 
I was given the opportunity to ask questions and all my doubts were clarified 
I know that my participation is voluntary and I can decide to withdraw any time I choose 
as well as refuse to answer any question uncomfortable to me 
I hereby agree to participate in this study. 
Guardian's signature/thumbprint: _________  
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Appendix 6: Infonnalion Sheel for adolescents less than ISyears 
Dear prospective participant, you have been invited to be part of this study. You can decide 
to participate or not. We have discussed this research with your parent(s)/guardian (s) and 
they know that we are also asking you for your decision. If you are going to participate in 
the research, your parent(s)/guardian will also have to agree. But if you do not wish to take 
part in the research, you do not have to, even if your parents have agreed. 
You may discuss anything in this fonn with your parents or friends or anyone else you feel 
comfortable talking to. You can decide whether to participate or not after you have talked it 
over. 
There may be some words you don't understand or things that you may want me to explain. 
Please ask me to stop at any time and I will take time to explain. 
Why have you been invited? You have been invited to be part of this study because you 
receive AntiretroviraI Treatment (ART) in this hospital. Please read the fonn carefully and 
ask any questions to clarify you before accepting to be part of the study. 
What is the aim of the research? The aim of this research is to find the factors that 
determine adherence to ART in Cameroon and the outcomes of treatment among 
adolescents with HIV. 
How are you going to participate? If you accept to take part, then your participation in the 
research starts signing the ascent fonn of acceptance. You will also be required to answer 
some on a questionnaire on some factors that may affect adherence. 
How long will the study last? The data collection will last for a period of three months, 
that is, from June to August. During this time we will interview you just one time to fill the 
questionnaire and this will last for about 10 minutes. 
What are the risks involved? We are going to take some of your time especially when we 
shall interview you. However, you have the right not to answer any question if you are 
uncomfortable with it. 
Possible Benefits: You will not receive any direct benefits from participating in this study 
and the care you will be given during your stay in the hospital will not depend on your 
participation in the study. However your participation in the study will help us to understand 
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the determinants of adherence and make possible recommendations to stake holders on how 
to improve on adherence in adolescents. 
Confidentiality: Any information you will provide in the questionnaire will be confidential 
and will be used only for the purpose of this study. No names will be written on the 
questionnaire, only numbers will be used. The information will be kept in our data base, 
coded and will not be used for any other purpose again. The code will only be known by the 
researcher. 
Right to withdraw: Taking part in the study is voluntary. After you have accepted to be 
part of the study, you have the right to withdraw at any time if you want to. It will also not 
be compulsory for you to explain why you have decided to withdraw from the study if you 
decide to leave. 
Contacts: You can call the principal investigator in case of further inquiries through; 
Mbuwir Charlotte: 674 08 S5 56. You can also contact Dr Edouard Katayi through 679 405 
849 if you have any ethical concerns. 
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Appendix 7: Written assent form for Adolescents less tban 18years 
Title of Thesis project 
DETERMINANTS OF ADHERENCE AND TREATMENT OUTCOMES AMONG 
ADOLESCENTS LIVING WITH HIV IN CAMEROON 
PARTICIPANT'S STATEMENTS OF ASENT 
If you have decided to participate in the study, please sign or thumb print in the space 
provided below: 
By participating in this study, you I agreed that, 
I have been infonned of the objectives and processes involved in this study. I also believe 
that I understand what is expected of me in this study. 
I understand how the data will be collected, what it will be used for and to whom it may 
be disclosed to. 
I was given the opportunity to ask questions and all my doubts were clarified 
I know that my participation is voluntary and I can decide to withdraw any time I choose 
as well as refuse to answer any question uncomfortable to me 
I hereby agree to participate in this study. 
Participant's signature/thumbprint: _________  
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Appendi~ 8: Questionnaire 
Adolescent ARV Adherence Study 
Participant NumberO=O Health Facility code rrr=J 
Date of interview(DDIMMlYY): ~_ 1_ _ 
Basic Information 
(Tick the letter corresponding to the correct answer) 
SN Question Answer 
1. Did participant give consent/ascent? a. Yes 
b.No 
(if no stop participant not eligible) 
2. Did guardian consent? a. Yes 
b.No 
(if yes continue to 3 and if No stop participant 
not eligible) 
3. How long (in months) have you been taking 
ARV drugs? 
Section 1: Demographic information 
(Tick the letter corresponding to the correct answer) 
SN Question Answer 
4. What is your sex? a.Male 
b. Female 
5. What is your exact age? a. 
b. Do not know 
6. What is your Occupation? 
7. What is your highest Level of a. Primary 
Education b. Secondary 
c. University 
d. None 
8. Where do you live? a. Urban 
b. Rural 
9. Who do you live with? a. Parents 
b. Guardians 
c. By myself 
10. What is your Religion? a. Christian 
b. Islam 
c. Others 
d. None 
11. How do you travel from home to the a. trekking 
hospital? b. bus 
c. taxi 
d. bike 
e. others 
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12. On average, how much time does it a. less than 30mins 
take you to travel from your usual h.30mins 
place of residence to the clinic? (in c. between 30mins to one 
minutes) hour 
d. more than an hour 
Section 2: Report to Hospital 
(Tick the letter corresponding to the correct answer) 
SN Question Answer 
13. How often do you visit the hospital? a. Once a month 
b. Every two 
months 
c. Every three 
months 
d. Others please 
specify 
e. Do not know 
14. Have you ever missed any of your hospital appointments? a. Yes 
(If no skip to question 17) b.No 
c. Do not know 
15. Which of the following possible reasons explain why you may 
have missed your hospital appointments? 
(Please tick Yes or No for each reason) 
a. Transportation problems getting to the clinic or pharmacy a. Yes 
b.No 
c. No response 
b. Did not have money a. Yes 
b.No 
c. Travelling out of town a. Yes 
b.No 
d. Was in School a. Yes 
b.No 
e. Did not just want to go a. Yes 
b.No 
f. Long waiting times in hospital a. Yes 
b.No 
g. Hospital staff do not attend to me well a. Yes 
b.No 
h. Forgot a. Yes 
b.No 
i. was sick a. Yes 
b.No 
j. others, please specify 
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Section 3: ARV Adherence 
(Tick the letter corresponding to the correct answer) 
SN Question Answer 
16. How long have you been on a. 
treatment? (in months) b. Do not know 
17. Do you know the name of the drug a. Yes 
your taking? b.No 
SN Question Answer 
18. If yes in above which ARV drug Name of Confirm N° of times per N° of 
are you currently taking? drug ed by day (dose per pills per 
checkin day) day 
g drug 
with 
patient 
a.once/d a_ _ 
b. twice/d b_ 
c. thrice/d c- -
19. How many times did you miss a. Yes 
your pills in the past 30days? b.No 
(If yes give number of doses) c. No response 
20. How many times did you miss 
your pills: 
Yesterday? a_ _ 
2 days ago? 
3 days ago? b_ _ 
One week ago? 
Did not miss any dose c_ _ 
No response 
21. How often do you feel that you a. All the time 
have difficulty taking your ARV b. Most of the time 
drugs on time? By 'on time' we c. Rarely 
mean no more than two hours d. Never 
before or two hours after the time 00. No response 
your doctor told you to take it 
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Section 4: Medication Interruptions 
(Tick the letter corresponding to the correct answer) 
SN Question Answer 
22. People may miss taking their medications for various reasons. 
Which of these possible reasons explain why you may have 
missed taking any medications? 
(Please tick Yes or No for the reasons) 
a. Yes 
a. Wanted to avoid side effects b.No 
00. No response 
a. Yes 
b. Was away from home b.No 
00. No response 
a. Yes 
c. Could not follow dietary instructions b.No 
00. No response 
a. Yes 
d. Religious beliefs b.No 
00. No response 
e. Not fully understanding the regimen and its requirements a. Yes 
b.No 
00. No response 
a. Yes 
f. Lost pills b.No 
00. No response 
a. Yes 
g. Forgot b.No 
00. No response 
a. Yes 
h. Didn't get prescription refilled/ran out of pills b.No 
00. No response 
i. Busy doing other things (e.g. working, schooling, trying to a. Yes 
survive. getting food) b. No 
00. No response 
a. Yes 
j. Tired of taking too many pills b.No 
00. No response 
a. Yes 
k. Other illness or health problem got in the way b.No 
00. No response 
I. Stigmatization (what others may say or discover about my a. Yes 
disease) b. No 
00. No response 
m. waking up early for work/school a. Yes 
b. No 
00. No response 
n. Didn't think I need it anymore; I can stay healthy without it a. Yes 
b. No 
00. No response 
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o. Didn't think they would really work a. Yes 
b.No 
00. No response 
a. Yes 
p. Took traditional medicines instead b.No 
00. No response 
others, please specify 
Section 5: Reasons for taking medications 
(Please tick Yes or No) 
SN Question Answer 
23. a.No 
Taking ARV drugs correctly makes me healthy b. Yes 
00. No response 
M L~ 
. I am determined to do whatever it takes to take my ARV b. Yes 
drugs on schedule. 00. No response 
25. I am determined to take my ARV drugs even if there is no a.No 
way to have privacy, such as in front of friends, family, or b. Yes 
co-workers. 00. No response 
26. a.No 
I take my medication even if I don't feel well. b. Yes 
00. No response 
27. a.No 
I take my ARV drugs to stay healthy for my family. b. Yes 
00. No response 
28. a. No 
Taking ARV drugs correctly makes me sick b. Yes 
00. No response 
29. In  th e next three months, I plan to take all doses of my ARV a.No 
drugs correctly b. Yes 
00. No response 
Section 6: Support from Health care providers 
(Please tick the letter corresponding to the correct answer) 
SN Question Answer 
30. a. None of the time 
How often do you doubt the information you get b. Sometimes 
from the clinic regarding the medications your c. Most of the time 
taking? d. All of the time 
00. No response 
31. 
How often do you worry that staff at the clinic may a. None of the time 
not keep the information you discuss totally b. Sometimes 
private? c. Most of the time 
d. All of the time 
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00. No response 
32. a. None of the time 
b. Sometimes 
Does the clinic staff do everything they can for your c. Most of the time 
health? d. All of the time 
00. No response 
Section 7: Method of Pay 
SN Question Answer 
33. The last time you obtained ARV drugs, did you pay a. No 
for the drug? b. Yes 
c. Do not know 
OO.No response 
34. If you paid for the drug, how much did it cost you? a. FCFA 
b. Do not know 
OO.No response 
35. If you paid for the drug, who paid for you? 
36. How was the money raised? 
Section 8: Internalised Stigma 
~Please tick the letter corresponding to the correct answer) 
SN Question Answer 
37. a. No one 
b. A few people 
How many people in the home you usually live in 
c. Most of the people 
know about your HIV status? 
d. All 
00. No response 
38. a. I Disagree 
It is difficult to tell other people about my HIV 
b. I 
infection Agree 
00. No response 
39. a. I Disagree 
Being HIV positive makes me feel dirty b. I Agree 
c. No response 
40. a. I Disagree 
I feel guilty that I am HIV positive h. I Agree 
00. No response 
41. a. I Disagree 
I am ashamed that I am HIV positive b. I Agree 
00. No response 
42. a. I Disagree 
I sometimes feel worthless because I am HIV positive b. I Agree 
00. No response 
43. a. I Disagree 
I hide my HIV status from others h. I Agree 
00. No response 
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Section 9: Perspective on adherence 
44. What is your understanding of adherence? a. taking HIV drugs 
everyday 
b. missing HIV drugs just 
once a week 
c. other 
45. What in your opinion do you think can be done so 
you adhere to treatment? 
a. reduce pills/doses a. Yes 
b.No 
b. reminder messages should be sent a. Yes 
b.No 
c. drugs should be brought home a. Yes 
b.No 
d. care providers should be more friendly a. Yes 
b.No 
e. other 
46. Do you have any questions? 
Thank you 
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Appendix 9: Dara Extrartion form for Adolescents on ARV treatment 
Patient nwnber: c:r=JD 
Health facility code: I 1::=1 
Identifier Code: '.= ....- ---.I_,,--..J 
Date(DDIMMlYYYY):_I_I_ 
Section A: Clinical Records 
a. (Fill the answers in the spaces provided and tick the letter corresponding to the correct 
answer where necessary) 
SN Question Answer 
1. Sex a.Male 
b. Female 
2. Age (years) 
3. Age of first clinic visit 
4. Date of ART initiation 
(DDIMMlYYYY) 
5. Did patient transfer into clinic? If yes a. Yes 
give date of transfer b.No 
c.Date~~_ 
6. Did patient start treatment elsewhere a. Yes 
before transferring into clinic? If yes b. No 
give date c. Date~~_ 
7. Date of ART initiation in this health 
facility(DDIMMNYYY) 
8. Did patient stop first treatment? If yes a. Yes 
give date and reason b. No 
c.Date~~_ 
d. Reason: 
9. Did patient start second treatment? If a. Yes 
give date b. No 
c.Date~~_ 
10. Did patient stop second treatment? If yes a. Yes 
give date and reason b. No 
c. Date I I 
d. Reason:- -
11. Did Patient start third treatment? If yes a. Yes 
give date b. No 
c. Date_I_ 1_ 
12. Name of Current treatment 
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Section B: Clinic visits 
Question Answers 
13. Date oflast clinic visit 
14. Dates of Previous visits. a. Yes 
Check the last 10 visits if patient has been b.No 
present. (Tick Yes for present and No for c. Date_I-.!_ 
absent) 
Visit 10 a. Yes 
b.No 
c. Date- .!_ /_ 
Visit 9 a. Yes 
b. No 
c. Date- .!- .!_ 
Visit 8 a. Yes 
b.No 
c. Date- .!- .!_  
Visit 7 a. Yes 
b.No 
c. Date- .!- .!_ 
Visit 6 a. Yes 
b.No 
c. Date- .!- .!_ 
Visit 5 a. Yes 
b.No 
c. Date _/_1_ 
Visit 4 a. Yes 
b.No 
c. Date_I-.!_ 
Visit 3 a. Yes 
b.No 
c. Date- .!- .!_ 
Visit 2 a. Yes 
b.No 
c. Date--f-f_ 
Visit 1 a. Yes 
b.No 
c. Date -.!- .!_  
Section C: CD4 Count Results 
List all the CD4 results in the patients chart starting from the oldest one to the most recent 
19. CD4 count Results (cells/mm3) Date (DDIMMlYYYY) 
pi 
2nd 
3rd 
41h 
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Section D: Viral load results 
List aU the CD4 results in the patients chart starting from the oldest one to the most recent 
20. Viral load results Results (copies/ml) Date (DD/MM/YYYY) 
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Pharmacy log book 
Patient number: COD 
Health facility code: 1=1=]~=1 
Identifier Code: CI ~ I=l 
Date(DDIMM/YYYY):_I_1_  
Tick the letter corresponding to the correct answer and fill where necessary 
SN Question Answer 
1. Sex a. Male 
b. Female 
2. Age(years) 
3. Current treatment 
Section E: ARV refill dates 
List the last AR V 12 refill dates in the patients chart starting from the most recent one 
4. ARVs Dates(DDIMMIYYYY) No of pills given 
Most recent (PI ) 
Next most recent (2nd ) 
3,d 
221 
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Appendix 10: Research Approval Letter from the North West Regional Delegation of 
Public Health 
r ItEPuBUQIJEoOU CAMEflOUN 
Po!.'( • Tt'(Jwll - Potrif! 
I MINrSTERE Of LA SANTE PUBLIQUE MINISTRY or PUBLIC HEALTH DELEGATION REGIONALE OU REGIONAL OELEGATION FOil THE 
I NORD OUEST NORTH WEST 
OAMEN!)A. the ... , . 
THE REGIONAL OfLE6A Tf 
L. Dtligue RCg'orlGl 
Fax: 233 36 11 04 
Tel: 233 363 289/6744933Z7 
To whom it may concern 
Subject: AUTHORISATION TO CARRYOUT RESEARCH 
MBUWIR Charlotte BONGFEN, a PHD student In the school of Public health In the 
University of -Chana is authorised to carry out her end of course research in the 
following Hospitals; Regional Hospital Bamentia, Banso Baptist Hospital, Ndap Distrid 
Hospital, St, Elizabeth Hospital Kumbo, on the topic: entitled "Detcrminan#5 of 
Adherence and. Treatment Outcomes Among Adolescents Living with HIli rn 
Cameroon", The research will run from September 2018 to February 2019 
You are hereby requested to give him the collaborotion needed 10 echic Ie the 
expected resul~s for this very Important acodemic exercise. 
This authorisation is issued to serve where eyer and whenever necessary. 
eel· 
-The concerned 
- File 
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Appendi>. II: Research Approval Letter from the West West Regional Delegation of Public Health 
~EPUBUC OF CAMEROON 
~EPUBUQue cu CAME~OUN 
Pall( - Travail - Potrl~ Peace - Work· Fatherland 
MINISTERE DE LA SANTE PUBLIQUE MINISTRY OF PUBLIC HEAL TH 
DELEGA TON REGIONALE REGIONAL DELEGATION 
DU SUD OUEST FOR THE SOUTH WEST 
Tel: 233 12 22 62 Regional Delegation Date:~' 2 .KIll 2018 
233 32 26 lB Reglonol Fund 
PD.BOX:281 Bu~ THE REGIONAL DELEGATE 
E:~fr:n~::hA:E/SWR/RCPHIPSI (~~ / I 0 tf~ 
TO: MBUWIR Charlotte BONGFEN. 
Department of Population. FClI11ily 
and Reproductive Health. 
University of Ghana 
SUBJEcr: Administrative Authorization to 
Colle:ct Research Data 
After a careful review of this study presented to us by this student, we are 
sure that medical ethics will be respected as the collection of data will be 
overseen by trained personnel after the consent of the participant has been 
obtained. 
With the clarity of her methodology and in view of the importance of this 
research in generating important information for the better management of 
patients, we have no objection to her carrying out her research on 
UOeterminonts of Adherence and Treatment outcomes Among Adolescents 
Living with HIV In Suea, Kumba, Limbe and Tiko Health OlstrictsH • 
I therefore call on the health facilities concerned and the participants to give 
this student the necessary assistance needed to enable her carryout this study 
of scientific importance. 
www.mlnsonte.emlwww.swrdp/l.org 
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Appendi. 12: Ethical Appro"al Letter from Cameroon Baptist Connntion Institutional Rc\ ie\\' Board 
--------------------_._--
CAMEROON BAPTIST CONVENTION HEALTH BOARD 
INS11T1JTIONAL REVIEW BOARD 
Julyl1.2tllB 
-~BongIon. 
CoIIagtolHealhSdl!nces. 
l./nIYeBIyolGlum 
charlJ!te.lmgIenQyoIIoo.<XlIn 
Re:IRII201l-tl, "DekrminanlJoI_ondtrealmontoutc_omongodoleo. .n tttlmg 
wltllHIV" 
OearC/latloUe, 
Yoorp<op08lld-.:hlllendlkl ...... ldIIanoIK:ellld .. deIem1inanls ....... _ 
___ among IdI:iIIII<:enD IHilQ willi HJV. Tho sUJy will also _ adoINoIInta· VIews on 
............ Thiswl....,.;delnlormationabottll1olr.l<j)I!CIations, beielalnl'"'!J9l'llllono_1ar ....o Ir 
"'"" end issuosolldhlnlnc8 to~I'" CXR*1lOd. 
v""'oIuly""*"""_~b1 .... lI1IIIN>oJIoI ... CBC_ao.dlRBlnlllas-.grll1l8d 
.~--'1Iio27".My.2018. YnurplUlDcol ... bo ....... lI .... nulBoonImoetingtothe 
enII19BaardilrfinlllllllRMlllnlan ....... boaenltoyouregardiw.j ... Boord'tdoclslon. 
_undertIlnINtisil ... lli:8lendaloty--,ilryouroUly. Yooll1USlpr_tI1iolRB 
"""""'"' Iobr to tho IbopbIAdmOiomIor and Chief ........ 0Ifi0w /or ........... to cia lho IIUdy In thai 
insIlIIIflon(l). 
llyou ...... .., ... I n .. .-dI""*""", ..... lmmacIaIaIysandU .. IRB .. ..-
.".,.;ryiIg"'cllqllljIIIpOIId. 
ThoBoard.,.. __. torllillUlyfora~""period. ThonIafter.boIonI,uY'l1.2019. 
you ... pJeaoeCClll1pleil ............. bmllinllfIIIOIIwIicII ... bollladwdto .. emaII and nUn Ito 
mo. Tho~bm ...... bolllVlewedand~byIheItlslidonllReWlwBoardtxb'tolhe 
..... indiondaleol ... amnl8ppIIlOIIIperIod. Tholaoto_aoUlypmllxxlllS 10,OOOda. 
Ynurpt'*"'>l .... booIIlI!IIIIanedlhe ...... l8ferencalRBproIDcU_.,.,~ID .. 
shouldlncMle: 
1. Tho IRB pmIIx:d runbor 
2. _oItheprinclpofln....aigBlDrond 
3. F"liIiIalthestudJ. 
F'tI1IIIy, .. -..:tI,~.""""'"lIldprusonlalionspertalninglolhe_probXlI,mustbo 
IIlbmiIIodtolwlRSilrpl'01llllbllonappR!VII. 
PIe8IO feeJ netocooQclmo willi IIII1questiono IOOIorconcems regarding'" above. CopIes tJf .. 
~~lhiIpn>pOIIIIlI1IUIbollWll1DmeInlIDZlIaAd1olOQ'll/ayoe-maii 
CBCHB!RBCIgrMI G!!\ 
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CAMEROON BAPTJST CONVENllON HEALTH BOARD 
INSTlTUTIONAL REVIEW BOARD 
Baptist centre. Nkwen. P.O. Il0l1. Bamenda. Northw.! Region 
January 10. 2019 
MbulWCIIarfoIt8Bongf11n, 
Sc:hocIdPublicHeallh. 
College of heaIIIt scienoes 
UnlvellilyatGhIna 
~J:Om 
IRBlludy IIUIIIber:: 1RB201a.t 1 
TllfeofProlDc:ol: "DetermInants 01"'-' MllIIuImenI ~-. 
IdalecentlIivIng willi HIV". 
IRB approyll dIh: July 77, 2018 
IRS upirlllod... ~ 17, 20111 
Dear Chat1otte, 
Your propa8ed ~ Intends 10 _ adhermce and lIB datetnWIanII as wei as InlaImenI 
outcomes among adolescents Iving YoiIh HIV. The AIdy wi liiio dIII!rmIne adcIescen1I' views on 
adherence. ThIs Will provide i1IonnaIIon about IhI/r mpacIaIIons, beIeII and suggestioot .. far IS !heir 
care and II8ues at adIIerenc:e \0 N{VllIr8 concemed. 
Your study protocol _ ruviIIwad by rnernbarI dille esc HeaIIh BoanIIR9 and ... gI8I1t8d 
expedIIed approval on 27Ih July, 2018. Your protocol ... presented to Ihe entil1l Bon at our last 
meeting. The Board aptllD\l8d)IU study. This Is,ourtlnal approvallellllr. 
Please understand 1IIaI1hII1s1he eIIIIcaI and safely I/IIPfUYII for )IU sIudy. You IIIIIf JII'IIStlIIIthlslRB 
approvaIletIir to Ihe HoIpitaIAdmIniIIIratIr and ChIef MedIcal 0fIlcer for IJPIlfOVIII \0 do the study In that 
1nItitution(8). 
If you mal!8 any changes In Ihe resean:II pIdIlcoI. please Immediately send the IRS an amendment 
specifying the changes JII'OIlO'ed. 
The BoIRl grants IIIIIJRMII for this study for a QI18o)"INI' time period. Thereafter, befoI1I July '0, 2019, 
you d pIeaIe~ our renewallormIIinaI n!ipOItllilk:ll wi be IIIached 10 111 emaft and return ft to 
me. The oompIeIed form IIIIIf be I8YIewad and IIppIQWd by the InstltutionaI RevIew BoIRl prior to the 
expIratfon daIB at the CUII8I1I approyaI period. The fee 10 RlMW.study protocol 1110,000 cia. 
Your protocol has been aasIgned Ihe abov8 ~ IRS protocol nllTblr. AI COIlllSpOIldence to UI 
sItouIdlnclude: 
1. ThelRBprotocoIl1UITIbef 
2. Nameofthe~lnVes1igaIorand 
3. Fulltltledthesludy. 
Finaly, aI abstnJcts, manUsa\pts, posIIn and pre5efltationll pertaIni1g 10 the abov8 protocol, rrust be 
submitted to the lAB for Pf1I1IUbIicatIo !IJlPIOYiI. 
Please feel he 10 cxnact me with any questions IIldfor COOOI!II1II regarding the abcM. CcpIe& d aD 
correspondence ftIGIIdInIIlhIs proposal should be sent 10 me and to ZJta Ad1a 118C181ary, e-mail 
escHBI 
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Appendix 13: Letter of Support for Ethical Clearance Application 
UNIVERSITY OF GHANA 
DEPARTMENT OF POPULATION, FAMILY 
AND REPRODUCTIVE HEALTH 
SCHOOL OF PUBLIC HEALTH 
Ret. No.: .' 
6 July 2018 
'The Clurinnan 
Cameroon Baptist Conventiun Health 
Institutional Review Boord 
(CllcHll-IRIl) 
Cmncruoll 
Dcar Ch.airrnan. 
APPI.lCATION FOR ETHICAL CLEARANCE 
J wrilll to support the application of Mbu"ir Charlotle lIongren, 8 PHD Studellt with the 
Dcptll1n1tmt or Population. Family and Reproductivc IIcahh. University of Ohano, School of 
Public Heallh. Legon. 
Hcr pruposallil1ed: wl)et.rmln.n'" of adherence and treatment ontcomes among adoks«nl. 
Ilvlnl with IIIV In CamenlOu" is "lioched for your review. 
Your cooperation "ould be very much Ill'preciallld. 
YoW'S faithfully. 
pn~~~:;=t 
(Head of Department) 
COLUGE OF HEAlTH SCIENCES 
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