Baseline characteristics of study participants
Table 1 summarizes the baseline characteristics of study population. The results from the 254/269 (94.4%) and 312/330 (94.5%) response rate of patients on NVP and EFV respectively with all the relevant data were analyzed. The median age of the patients was 41 years (IQR = 35–47 years), with a median duration of living with HIV infection of five years (IQR = 1–11years) and a median duration since ART initiation of three years (IQR = 1–8 years). Among these patients 342 (60.4%) were female, 379 (67%) were married, 367(64.8%) were Bantus, 106 (18.2%) had a previous partner who died. Only 3.5% and 5.8%; 19.7% and 17.3% (on NVP and EFV respectively) were currently smoking and taking alcohol respectively. Out of 254 patients on NVP and 312 on EFV, majority 74.4% and 73.3% stated the difficulties disclosing their HIV status. On the contrary, the majority 79.1% and 75.9%; 68.1% and 65.4% (on NVP and EFV respectively) did not feel immoral or guilty for being HIV positive, respectively. Both patients on NVP and EFV, majority did not feel ashamed or worthless for being HIV positive and were very ready to tell their primary sexual partner of their HIV status. The majority 85% (NVP) and 78.2% (EFV) got as much as would like useful advice about important things in life (p = 0.022). Similarly, the majority of these patients got as much as possible chance to talk to someone about work/household problems, about personal/family problem, people who cared about their situations and got as much love and affection. Majority of the patients also got emergency financial and transportation support but there was no significant difference by ART regimen. Other than age (p = 0.046) and number of life sexual partners (p = 0.019), there was no significant difference in the baseline characteristics between patients on NVP and those on EFV.
Table 1. Baseline characteristics of the study patients
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ART adherence
In this study non-adherence was defined as missing to take current ART or missing to take ART dose in the past 30 days. Among all the study patients 371(n = 566; 65.6%); 164(n = 254; 64.6%) on NVP and 207(n = 312; 66.3%) on EFV reported non-adherence in the last 30 days (Fig. 1).
Efavirenz and Nevirapine plasma concentration
Among the patients on nevirapine based ART regimen, the majority (54.3%) had plasma levels of > 6000 ng/ml considered levels for durable viral suppression. There were 80 (31.5%) patients with NVP levels between 3400 to 6000ng/ml considered levels for viral mutant selection windows and the least 36 (14.2%) who had NVP plasma concertation of < 3400 ng/ml considered levels for poor viral suppression (p < 0.05). For patients on efavirenz based ART regimen, the majority (63.8%) had plasma concentrations between 1000 to 4000ng/ml considered levels for viral mutant selection windows with some 14(4.5%) had plasma concentrations of < 1000 ng/ml considered levels for poor viral suppression window (p < 0.05).
Relationship between HIV related stigma, disclosure and social support and ART adherence
HIV stigma, disclosure and social support related factors influence the drug plasma level by affecting drug adherence. The study first assessed the relationship between social physiological status variables with ART drug adherence and only those factors found significant were then evaluated against drug plasma level. Among these factors included, gender, age, substance abuse, age of sexual debut, number of sexual life partners. Among HIV stigma related factors assessed included; feeling guilty for being HIV positive, hiding HIV status from others and feeling certain to tell primary sexual partner about HIV status. HIV disclose related factors included being able to disclose HIV status to anyone and disclosing the HIV status to family members. Among HIV social support related factors assessed included; getting useful advice about important things in life, getting chance to talk to someone about work or household problems, getting love and affection, being helped with household duties, getting financial and transportation help. Nutritional related factors included: Regular access to staple food, regular uptake of porridge, access to food supplements, Food intake in the last 5–10 days, presence of wasting and feeding syndrome risk (Table 2).
Table 2. Relationship between HIV stigma, disclosure and social support and ART drug adherence
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Variation in efavirenz and nevirapine plasma level HIV stigma, disclosure and social support related variables
Table 3 summarizes the variation in the median NVP and EFV plasma concentration and socio-demographic, sexual behavior, HIV stigma and disclosure characteristic. Patients who disclosed their HIV status to their employer had higher median (IQR) EFV plasma concentration (3157, IQR = 2001–5976 ng/mL) than those that did not (2173.5, IQR = 1655.5–3208.5 ng/mL; p = 0.041). Patients who did not disclose their HIV status to religious leaders had higher median (IQR) EFV plasma concentration (2821.5, IQR = 1945–5270 ng/mL) than those who did (1998.5, IQR = 1548–2520 ng/mL; p = 0.0031). Further, patients who disclosed their HIV status to the public had higher median (IQR) EFV plasma concentration (3097, IQR = 2872–5976 ng/mL) as compared to patients who did not (1965, IQR = 1639–2763 ng/mL; p = 0.0117).
Table 3. Variation in median efavirenz and nevirapine plasma concentration and HIV stigma, disclosure and social support related variables
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Patients with higher median (IQR) EFV plasma concentration were those who did not feel guilty for being HIV positive (6511, IQR = 4607–9863 ng/mL) as compared to patients who felt guilty (5557, IQR = 4247–7633 ng/mL; p = 0.0163). Patients who disclosed their HIV status to their spouse (6402.5, IQR = 4564.5–9180.5 ng/mL) had higher median (IQR) NVP plasma concentration than those who did not (4853, IQR = 3450–6202 ng/mL; p = 0.0362).
Factors associated with drug plasma concentration
Stigma
In multivariate linear regression analysis, feeling guilty for being HIV positive (adjusted β = 954, 95% CI = 192.7 to 2156.6; p = 0.014) or feeling worthless for being HIV positive (adjusted β = 852, 95% CI = 64.3 to 1639.7; p = 0.034) were independent factors associate NVP plasma concentrations. For patients on EFV, being certain of telling the primary sexual partner about HIV positive status was associated with increased EFV plasma levels (adjusted β 363, 95% CI, 97.9 to 628.1; p = 0.007) (Table 4).
Table 4. Regression analysis between NVP and EFV plasma concentrations and HIV stigma variables
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Disclosure
In multivariate linear regression analysis, disclosing patient’s HIV status to neighbors (adjusted β = 1731, 95% CI = 376 to 3086; p =0.012) was associated with increased NVP plasma concentrations. None of the HIV disclosure related factors were associated with EFV plasma concentrations (Table 4).
Social support
In multivariate linear regression analysis getting transportation to hospital whenever needed (adjusted β = -1143.3, 95% CI = -1914.3 to -372.4; p =0.004) was associated with lower NVP plasma concentrations. None of the HIV social support related factors were found associated with EFV plasma concentrations (Table 4).