A total of adolescents who are on ART (101 cases and 196 controls) were participated in the study making the response rate 100%. The mean age of control participants was 14.9 years with SD of 2.8 years while the mean age for case participants was 15 years with SD of 2.8 years. About 58(57.4%) cases and 119(60.7%) controls were Females. (table 1) .
Table 1: - Socio-demographic Characteristics of Adolescent on ART in Guji zone health facilities, Ethiopia, 2018.
Variables Categories
|
Cases (%)
|
Controls (%)
|
Sex
|
Male
|
43(42.6%)
|
77(39.3%)
|
Female
|
58(57.4%)
|
119(60.7%)
|
Age category
|
10-14
|
44(43.6%)
|
88(44.9%)
|
15-19
|
57(56.4%)
|
108(55.1%)
|
Residence
|
Town
|
56(55.4%)
|
124(63.3%)
|
Rural
|
45(44.6%)
|
72(36.7%)
|
Religion
|
Orthodox
|
47(46.5%)
|
92(46.9%)
|
Muslim
|
5(5.0%)
|
27(13.8%)
|
Protestant
|
45(44.6%)
|
72(36.7%)
|
Catholic
|
4
|
5
|
Caregivers Marital
status
|
Single
|
17(16.8%)
|
22(11.2%)
|
Married
|
43(42.6%)
|
111(56.6%)
|
Divorced
|
19(18.8%)
|
40(20.4%)
|
Widowed
|
13(12.9%)
|
19(9.7%)
|
Separated
|
9(8.9%)
|
4(2.0%)
|
caregivers Educational
status
|
Can’t read and write
|
15(15%)
|
23(11.7%)
|
Able to read and write
|
15(15%)
|
26(13.3%)
|
formal education
(grade1-8)
|
58(57%)
|
113(57.7%)
|
High school and above
|
13(4.4%)
|
34(17.3)
|
Ethnicity
|
Oromo
|
48(47.5%)
|
99(50.5%)
|
Amhara
|
21(20.8%)
|
41(20.9%)
|
Tegaru
|
5
|
6(3.1%)
|
Sidama
|
22(21.8%)
|
41(20.9%)
|
Others(Gedeo, Guraghe)
|
5
|
9(4.6%)
|
Caregivers Employment
status
|
Employed
|
75(74.3%)
|
169(86.2%)
|
Unemployed
|
26(25.7%)
|
27(13.8%)
|
Adolescents occupational status
|
Unemployed
|
5
|
12(6.1%)
|
Drivers
|
10(9.9%)
|
13(6.6%)
|
Students
|
46(45.5%)
|
94(48.0%)
|
Daily laborers
|
13(12.9%)
|
33(16.8%)
|
Merchants
|
16(15.8%)
|
24(12.2%)
|
Commercial sex workers
|
9(8.9%)
|
14(7.1%)
|
Others (shoeshine etc.)
|
2
|
6
|
Adolescents Living
condition
|
Live with family
|
75(74.3%)
|
140(71.4%)
|
Live with other adult or children
|
9(8.9%)
|
17(8.7%)
|
Live alone
|
17(16.8%)
|
39(19.9%)
|
Clinical Characteristics of Adolescents
Majority of cases 88(87.1%) and 164(83.7%) controls were from health centers. Fifty nine (58.4%) cases and 109(55.6%) controls were categorized as WHO clinical stage II. All controls 196(100%) have greater than 95% self/caregiver reported adherence over past one month (table 2).
Table 2: Clinical Characteristics of Adolescent on ART in Guji zone health facilities, Ethiopia, 2018.
Variables(N=297)
|
Categories
|
Cases (%)
|
Controls (%)
|
Health Facility Types
|
Health center
|
88(87.1%)
|
164(83.7%)
|
Hospital
|
13(12.9%)
|
32(16.3%)
|
WHO Clinical staging
|
Stage I
|
27(26.7%)
|
61(31.1%)
|
Stage II
|
59(58.4%)
|
109(55.6%)
|
Stage III
|
13(12.9%)
|
20(10.2%)
|
Stage IV
|
2
|
6(3.1%)
|
ART Drug Regimen
|
First line
|
99(98.0%)
|
191(97.4%)
|
Second line
|
2
|
5
|
Baseline CD4 Count
|
<350cells/mm
|
31(56.4%)
|
60(53.6%)
|
>350cells/mm
|
24(43.6%)
|
52(46.4%)
|
Latest CD4 count
|
< 500ells/mm
|
26(25.7%)
|
26(13.3%)
|
>500cells/mm
|
72(71.3%)
|
152(77.5%)
|
self-reported adherence (30 days)
|
<95%
|
98(97%)
|
0
|
> 95%
|
3
|
196(100%)
|
Reason for missing ART drugs Among Adolescents
The reason for missing ART drugs among adolescents about 66(33.7%) controls who have missed < 2 doses in past one month recall as well as who were adherent on their 3 and 7 days recall and all cases were responded on their reason for missing ART drugs. (figure 1).
Factors Associated with Nonadherence on Binary Logistic Regression
Unmarried/widowed/separated caregivers with COR 1.8(1.1-2.9), source of income (unemployed) with COR 2.2(1.2-3.9) and area of residence (rural) COR 1.4(.85-2.3) were found to be a candidate variables associated with non-adherence status of the adolescents from socio-demographic factors (table 3).
Table 3: Socio-demographic factors associated with non-adherence of Adolescent on ART in Guji zone health facilities, Ethiopia, 2018.
Variables
|
Categories
|
Cases (%)
|
Controls (%)
|
COR (95%CI)
|
P.Values
|
Sex
|
Male
|
43(42.6%)
|
77(39.3%)
|
Reference
|
|
Female
|
58(57.4%)
|
119(60.7%)
|
0.87(.54- 1.4)
|
0.584
|
Age
|
10-14
|
44(43.6%)
|
88(44.9%)
|
Reference
|
|
15-19
|
57(56.4%)
|
108(55.1%)
|
0.95(.58- 1.5)
|
0.827
|
Marital status
of caregiver
|
Married
|
43(42.6%)
|
111(56.6%)
|
Reference
|
|
Single, widowed/separated
|
58(57.4%)
|
85(43.4%)
|
1.8(1.1-2.9)
|
0.022*
|
Family living
together
|
Both are alive
|
51(50.4%)
|
101(51.5%)
|
Reference
|
|
One or both dead
|
50(49.6%)
|
95(48.5%)
|
1.04(0.64-1.7)
|
0.866
|
Adolescents Educational status
|
Attended formal
education
|
71(70.3%)
|
147(75%)
|
Reference
|
|
Not attended formal education
|
30(29.7%)
|
49(25%)
|
1.3(0.74-2.2)
|
.385
|
Sources of
Income
|
Employed
|
75(74.3%)
|
169(86.2%)
|
Reference
|
|
Unemployed
|
26(25.7%)
|
27(13.8%)
|
2.2(1.2-3.9)
|
0.012*
|
Monthly Income
|
<1000ETB
|
33(32.7%)
|
72(36.7%)
|
Reference
|
|
>=1000ETB
|
68(67.3%)
|
124(63.3%)
|
1.2(0.72-2.0)
|
0.48
|
Living arrangement
|
With Family
|
75(74.3%)
|
140(71.4%)
|
0.87(.50-1.5)
|
0.606
|
Living alone
|
26(25.7%)
|
56(28.6%)
|
Reference
|
|
Residence
|
Town
|
56(55.4%)
|
124(63.3%)
|
Reference
|
|
Rural
|
45(44.6%)
|
72(36.7%)
|
1.4(.85-2.3)
|
0.192*
|
* P-value less than 0.25
Psychosocial Related Factors Associated with Non-adherence to ART
Psychosocial related variables that were found to be candidate variables were, not disclosing HIV status COR 4.6(2.7-7.7), adolescents without family support COR 1.9(1.1-3.4), no satisfaction to family support by adolescents COR .54(0.25-1.19), adolescents/caregivers who are not using method to remind drug taking time COR 1.5(.86-2.7), have experienced family death by adolescents with COR 1.4 (0.89-2.35), (Table 4).
Table 4: Psychosocial factors associated with non-adherence among of Adolescent on ART in Guji zone health facilities, Ethiopia, 2018.
Variables
|
Categories
|
Cases (%)
|
Controls (%)
|
COR (95%CI)
|
P. Values
|
Disclosure status
|
Not disclosed
|
57(56.4%)
|
43(22%)
|
4.6(2.7-7.7)
|
0.000*
|
Disclosed
|
44(43.6%)
|
153(78%)
|
Reference
|
|
Family support
|
No
|
31(30.7%)
|
36(18.4%)
|
1.9(1.1-3.4)
|
0.017*
|
Yes
|
70(69.3%)
|
160(81.6%)
|
Reference
|
|
Satisfaction to
support family
|
No
|
9(8.9%)
|
30(15.3%)
|
|
|
Yes
|
92(91.1%)
|
166(84.7%)
|
|
|
Reminder method used
|
Yes
|
74(73.3%)
|
158(%80.6)
|
Reference
|
|
No
|
27(26.7%)
|
38(19.4%)
|
1.5(.86-2.7)
|
0.148*
|
Experienced family death
|
One or more
|
50(49.5%)
|
79(40.3%)
|
1.5 (0.89-2.4)
|
0.130*
|
No one died
|
51(50.5%)
|
117(59.7%)
|
Reference
|
|
Depression status
|
Have depression
|
45(44.5%)
|
38(19.4%)
|
3.3(1.9-5.7)
|
0.000*
|
No depression
|
56(55.5%)
|
158(80.6%)
|
Reference
|
|
Internalized stigma status
|
Experienced
|
61(60.4%)
|
97(49.5%)
|
1.5(0.95-2.5)
|
0.075*
|
Not experienced
|
40(39.6%)
|
99(50.5%)
|
Reference
|
|
Discrimination status
|
Experienced
|
54(53.5%)
|
83(42.3%)
|
1.2(0.72-1.9)
|
0.491
|
Not experience
|
47(46.5%)
|
113(57.7%)
|
Reference
|
|
Substance use in past one month
|
Alcohol Drinking
|
Yes
|
41(40.6%)
|
43(21.9%)
|
2.4(1.4-4.1)
|
0.001*
|
No
|
60(59.4%)
|
153(78.1%)
|
Reference
|
|
Cigarettes Smoking
|
Yes
|
11(10.9%)
|
10(5%)
|
2.3(0.9-5.5)
|
0.071*
|
No
|
90(90.1%)
|
186(95%)
|
Reference
|
|
Khat chewing
|
Yes
|
24(23.7%)
|
19(9.6%)
|
2.9(1.5-5.6)
|
0.002*
|
No
|
77(76.3%)
|
177(90.4%)
|
Reference
|
|
|
|
|
|
|
|
|
|
|
* P-value less than 0.25
Health Care Delivery System Related Factors Associated with Non-Adherence
Only adolescents who are following drugs instruction provided by health care provider half of the time or less time with COR 1.9(1.1-3.6) was found to be candidate variable associated with adherence status from health care delivery system related factors(table 5).
Table 5: Health care delivery system related factors associated with non-adherence of Adolescent on ART in Guji zone health facilities, Ethiopia, 2018.
Variables
|
Categories
|
Cases (%)
|
Controls
(%)
|
COR (95%CI)
|
P.Values
|
Health facility
distance
|
<=5 KM
|
63(62.4%)
|
115(62.2%)
|
Reference
|
|
>5 KM
|
38(37.6%)
|
74(37.8%)
|
0.94(0.57-1.5)
|
0.799
|
Duration to reach H/F
|
>60 minutes
|
31(30.7%)
|
51(26%)
|
1.3(0.74-2.1)
|
0.394
|
<=60 minutes
|
70(69.3%)
|
145(74%)
|
Reference
|
|
Means of travel to H/F
|
Vehicles/motor
|
68(67.3%)
|
124(63.3%)
|
Reference
|
|
On foot
|
33(32.7%)
|
72(36.7%)
|
0.83(.50-1.4)
|
0.488
|
counseled
|
No
|
1
|
2
|
|
|
Yes
|
100(99%)
|
194(98.9%)
|
|
|
Privacy kept
|
No
|
3
|
5
|
|
|
Yes
|
98(97%)
|
191(97.4%)
|
|
|
instruction for
drug
|
No
|
44(43.6%)
|
81(41.3%)
|
1.1(0.67-1.8)
|
0.711
|
Yes
|
57(56.4%)
|
115(68.7%)
|
Reference
|
|
Following instruction
|
Mostly
|
76(75.2%)
|
168(85.7%)
|
Reference
|
|
sometimes
|
25(24.8%)
|
28(14.3%)
|
1.9(1.1-3.6)
|
0.027*
|
Facility types
|
HC’s
|
88(87.1%)
|
164(83.7%)
|
Reference
|
|
Hospitals
|
13(12.9%)
|
32(16.3%)
|
1.3(0.66-2.6)
|
0.432
|
Health professional experience
|
Least experienced
|
6(6%)
|
18(9.2%)
|
|
|
Experienced
|
95(94%)
|
178(90.8%)
|
|
|
|
|
|
|
|
|
|
* P-value less than 0.25
Disease related factors associated with non-adherence to ART
Two variables; latest CD4 count > 500mm/cells with COR 0.47(0.26-0.87) and adolescent who use other drugs besides ART COR 2.1(1.3-3.5) were identified from disease related factors to be candidate variables associated with non-adherence status of the adolescents ( Table 6).
Table 6: disease related factors associated with non-adherence of Adolescent on ART in Guji zone health facilities, Ethiopia, 2018.
Variables
|
Categories
|
Cases (%)
|
Controls (%)
|
COR(95%CI)
|
P.Values
|
ART pills taken at once
|
1(One)
|
62(61.4%)
|
118(60.2%)
|
Reference
|
|
>2(Two)
|
39(38.6%)
|
78(39.8%)
|
0.95(0.58-1.6)
|
0.843
|
Daily frequency ART
|
Once
|
52(51.4%)
|
88(44.9%)
|
Reference
|
|
Twice or
above
|
49(48.6%)
|
108(55.1%)
|
0.77(.47-1.2)
|
0.282
|
Duration on
ART
|
<2 years
|
26(25.7%)
|
51(26%)
|
Reference
|
|
> 2 years
|
75(74.3%)
|
145(74%)
|
1.0(0.57-1.8)
|
0.959
|
Baseline CD4count
|
<350cells/mm
|
31(56.4%)
|
60(53.6%)
|
Reference
|
|
>350cells/mm
|
24(43.6%)
|
52(46.4%)
|
1.1(0.58-2.1)
|
0.733
|
Missing
|
46(45.5%)
|
87(45.4%)
|
|
|
Latest CD4
Count
|
<500cells/mm
|
26(25.7%)
|
26(13.3%)
|
Reference
|
|
>500cells/mm
|
72(71.3%)
|
152(77.5%)
|
0.47(.26-0.87)
|
0.017*
|
Missing
|
3
|
18(9.2%)
|
|
|
WHO clinical
Staging
|
Stage I & II
|
86(85.1%)
|
170(86.7%)
|
Reference
|
|
Stage III & IV
|
15(14.9%)
|
26(13.3%)
|
1.1(0.57-2.3)
|
0.707
|
Other drugs
besides ART
|
Yes
|
44(43.7%)
|
52(26.5%)
|
2.1(1.3-3.5)
|
0.003*
|
No
|
57(56.3%)
|
144(73.5%)
|
Reference
|
|
ART regimen
|
First line
|
99(98%)
|
191(97.4%)
|
|
|
Second line
|
2
|
5(2%)
|
|
|
*significant at p. value less than 0.25
Multivariable logistic regression Analysis
After running backward stepwise multivariable logistic regression; Residence, Marital status of caregiver, sources of income for family, disclosure status, depression status of adolescents, uses of reminding method and uses of other drugs besides ART were found to be significantly associated with non-adherence to ART among adolescents. Being rural resident is associated with nonadherence to ART among adolescents. Adolescents who resides in rural area have 1.9 times less like to adhere to ART compared to those residing in urban AOR=1.9(1.1-3.6). Adolescents who lives with unemployed caregivers were 4.2 times less likely to adhere to ART compared to those with employed caregivers with AOR 4.2(2.0-8.9 (Table 7).
Table 7: Multivariable Logistic Regression Analysis of factors associated with non- adherence among of Adolescent on ART in Guji zone health facilities, Ethiopia, 2018.
Factors
|
Categories (N=297)
|
Cases (%)
|
Controls (%)
|
AOR(95%CI)
|
P. Values
|
Residence
|
Rural
|
45(44.6%)
|
72(36.7%)
|
1.9(1.1-3.6)
|
0.026**
|
Town
|
56(55.4%)
|
124(63.3%)
|
Reference
|
|
Uses of
Other drugs
besides ART
|
Yes
|
44(43.7%)
|
52(26.5%)
|
2.6(1.5-5.0)
|
0.002**
|
No
|
57(56.3%)
|
144(73.5%)
|
Reference
|
|
Disclosure status of Adolescent
|
Disclosed
|
44(43.6%)
|
153(78%)
|
Reference
|
|
Not disclosed
|
57(56.4%)
|
43(22%)
|
5(2.8-9.4)
|
0.000**
|
Caregiver Marital status
|
Unmarried/widowed/separated
|
58(57.4%)
|
85(43.4%)
|
2.1(1.2-3.8)
|
0. 012**
|
Married
|
43(42.6%)
|
111(56.6%)
|
Reference
|
|
Family income
Source
|
Employed
|
75(74.3%)
|
169(86.2%)
|
Reference
|
|
Unemployed
|
26(25.7%)
|
27(13.8%)
|
4.2(2.0-8.9)
|
0.000**
|
Adolescents Depression status
|
No depression
|
56(55.5%)
|
158(80.6%)
|
Reference
|
|
Have depression
|
45(44.5%)
|
38(19.4%)
|
2.7(1.5-4.9)
|
0.002**
|
Alcohol use in past one month
|
Yes
|
41(40.6%)
|
43(21.9%)
|
1.1(0.5-2.3)
|
0.9
|
No
|
60(59.4%)
|
153(78.1%)
|
Reference
|
|
Reminding method
use
|
Yes
|
74(73.3%)
|
158(80.6%)
|
Reference
|
|
No
|
27(26.7%)
|
38(19.4%)
|
2.4(1.2-4.8)
|
0.014**
|
Internalized stigma
|
Not experienced
|
40(39.6%)
|
99(50.5%)
|
Reference
|
|
Experienced
|
61(60.4%)
|
97(49.5%)
|
1.8(.98-3.1)
|
0.060
|
**factors significantly associated with nonadherence to ART at P. Value < 0.05