This study aimed to identify factors contributing to ART non-adherence and viral failure in prisoners in South Ethiopia. Prisoners had a level of viral suppression (94%) which is close to the third goal of the Joint United Nations Programme on HIV/AIDS (UNAIDS), i.e. achieving viral suppression in 95% of treated individuals by 2030 [65]. They also had a lower prevalence of NA and VF than that commonly reported in SSA general populations [66, 67] including that of Ethiopia [68, 69], as well as in prison populations internationally [9–11, 15, 16, 19, 20, 22, 70]. However, NA and VF prevalence amongst prisoners in this study was higher relative to the local non-incarcerated population. The recent and rapid expansion of ART services in Ethiopia might have contributed to the positive treatment outcomes in this study [4, 71], but the discrepancy between incarcerated and non-incarcerated individuals may suggest an inequitable access to standard HIV care between community- and correctional facility-based populations. The findings also indicate the importance of a patient’s compliance with specified doses for achieving viral suppression [72, 73], which predicts HIV-related morbidities and mortality, as well as further transmission [1–3].
Various structural, psychosocial, individual and clinical factors were identified to influence ART adherence and viral suppression in ILWHA relative to non-incarcerated PLWHA. While missing ART appointments was an important factor affecting adherence in both incarcerated and non-incarcerated populations, it appeared to be more critical in ILWHA. Regular clinic visits are essential for ART clients in order to receive ongoing adherence counselling and support services, as well as clinical assessment and further prescription of ART [52]. Omission of such appointments, therefore, subsequently leads to sub-optimal adherence and facilitation of community transmission [6, 52, 57, 74–78]. Prisoners in low-income countries often access ART services from external public health care facilities, which presents serious of institutional barriers (e.g. a lack of transport facilities and uncooperative security system) [30, 32]. We recommend implementation of standard HIV care package in the prison system as supported by international guidelines [38, 79, 80].
A significantly lower level of satisfaction with ART services was observed in ILWHA than non-incarcerated PLWHA. This is important because the results revealed an 86% lower likelihood of dose adherence in clients who had low satisfaction. Furthermore, the odds of dose adherence were 75% lower in ILWHA who had received ART services from a hospital compared to those who were receiving ART services from a health centre. The importance of good health care provider-patient relationships for enhancing adherence is well recognised both in prison [21, 28, 29] and community-based populations [74, 81]. It is also known that when patients believe that health care providers are uncaring and unsympathetic, their ability to conform to medication instructions will be negatively affected [35, 82]. However, health care provider- and health facility-related issues are amongst the most frequently reported barriers to ART adherence in SSA [83]. Health care facilities in SSA, particularly hospitals, often serve a large volume of patients, which leads to a long waiting time, overcrowding and loss of patient privacy [83]. The findings therefore suggest a need for decentralisation of ART services to primary health care facilities including prison clinics. Training of health care providers in HIV care provision is pivotal to achieve this, in addition to reinforcing collaboration between prison and community healthcare systems [84].
Our study showed a significant decrease in the odds of adherence in depressed prisoners and in those who lacked social support. Although depression strongly predicts NA in the community-based populations as well [82, 85, 86], ILWHA often feel depressed due to concerns related to imprisonment [38] and HIV infection itself [87]. Global and local studies identified depression as one of the main predictors of NA in prison populations [18, 28, 34]. The positive impact of social support on prisoners’ ART adherence and the likely increase in the risk of NA when ILWHA suffer from social isolation is well recognised [18, 20, 21, 36, 88, 89]. Thus, in addition to enhancing peer support programs in prison settings [18, 20, 21, 36], integration of HIV care and treatment of medically diagnosed depression is likely to be essential for maintaining ART adherence in prisoners.
Among the individual level factors assessed in this study, the ability to comply with a specified medication schedule determined dose adherence in incarcerated and non-incarcerated ART clients. Our study also signified that the type of methods clients used to manage their medication schedule affected dose adherence. For example, dose adherence significantly decreased in clients who used news time on radio/TV or other social cues compared to those who used more direct methods, such as mobile phones and/or wristwatches. Research shows that patients’ ability to comply with medication instructions generally increases when they perceive good efficacy and safety of ART [20, 34, 81]. In addition, the use of reminder devices such as telephone reminders, clocks and alarms has been associated with a significant increase in ART adherence [90–92]. Adapting such interventions to prison context and the specific needs of prisoners is required.
In the current study, ILWHA who experienced viral failure had a significantly lower MPR adherence. Prior studies have shown that having NA lessens the likelihood of viral suppression in both prison- [20] and community-based populations [43, 93–95]. However, the current study provided no evidence regarding such a relationship, which might be due to the small number of participants who had developed the clinical outcomes. Nonetheless, people with a higher plasma viral load [96–98] and other disease symptoms [20, 28] often find it challenging to consistently use their medication. This could be related to a high pill burden and potential drug interactions that are likely to occur during the advanced stages of HIV infection due to opportunistic infections [66, 99, 100]. The finding underscores the importance of early HIV treatment for achieving optimal adherence in prisoners.
This study identified a significantly higher likelihood of VF in males, people in the age group of 31 to 35 years and in those who encountered or perceived social stigma, irrespective of their incarceration status. Prior studies also showed higher odds of viral suppression in female prisoners than male prisoners [101]. With limited evidence available regarding the mechanism of how gender influences viral suppression, females often conform better to ART in the community settings [66, 68, 97], which might have also facilitated their adherence during incarceration.
Younger age (below 35 years) has been frequently reported to be associated with a higher risk of NA and VF in both incarcerated [18, 22] and non-incarcerated populations [66–68, 95, 102]. People in this age group are generally more likely to adopt substance misuse behaviours and often encounter social stigma and discrimination [103]. They are also more likely to initiate ART late [104–107], which may lead to subsequent NA and VF [95–98, 108]. Young adult males predominate prison populations in South Ethiopia [109] and around the world [110, 111], and they have a high prevalence of HIV infection compared to other age groups [112, 113]. Group specific HIV care intervention strategies including provision of adequate educational information about HIV and the importance of a consistent use of ART, are highly recommended.
The significant positive association between social stigma and VF in this study may reflect the adverse effect of alienation on a patient’s appropriate use of medication [99, 114, 115], which is particularly profound in prison populations [27–30]. Nonetheless, there existed no statistically significant association between social stigma and self-reported or pharmacy refill adherence in this study, which may represent a lower specificity of both methods in detecting adherence relative to plasma viral load measurement [51, 53, 116, 117]. Educational interventions are required to reduce this health related social stigmatisation by improving a general understanding of HIV amongst prison staff and prisoners [118].
This study had a few limitations. Approximately one quarter of correctional facilities present in South Ethiopia were included in the study based on the size of their prison populations. While there was no variation in treatment outcomes based on the type of correctional facility, it is still possible that ILWHA who were in other prisons may have had different outcomes. A nationally representative study is required to draw conclusions that are illustrative of the prison populations in Ethiopia. Given the high turnover amongst prisoners and the high prevalence of sub-optimal ART outcomes in recidivists [119, 120], the prevalence of NA and VF might have been underestimated in incarcerated people. Factors that affect ART outcomes throughout the incarceration cycle (during arrest, stay in jail, stay in prison and after release) should be longitudinally investigated by examining individuals at each stage of incarceration.
The participants’ true compliance to medication might have been over- or under-estimated as adherence in this study was measured using self-report and pharmacy refill methods [116, 117]. Self-reported adherence is likely to be threatened by recall and social desirability bias [117]. To minimise the effect of recall bias, short term (the previous four days) adherence was measured so that the participants’ memories about doses would be clearer. Strategies that could reduce the participants’ perceptions of the possible consequences of reporting adherence or non-adherence (such as reinforcing the importance of reporting both adherence and non-adherence for the research project, and reassurance that the information provided would not affect their care) were used to minimise social desirability bias. The pharmacy refill method of adherence measurement does not guarantee that clients could not obtain drugs from sources other than the reporting pharmacy, or provide information about when and how they take the medication [117]. Nonetheless, public health care facilities in the study area were almost exclusively providing ART services, which might have minimised an oversupply of drugs as only such institutions were involved in this study. In addition, when self-report and pharmacy refill methods are used in conjunction, the weakness of one approach could be offset by the strength of the other [117].