Table 3
Viral suppression following unsuppressed Viral Load from Jan 2015 to Oct 2018 and associated factors
Variable | Not suppressed (n = 310) | Suppressed (n = 189) | Crude PR | P-value | adj PR | 95%CI | P-value |
Intervention | | | | | | | |
SOC | 129 (73.7) | 46 (26.3) | 1 | | 1 | | |
IAC | 181 (58.9) | 143 (44.1) | 1.68 | > 0.001 | 1.22 | 1.01–1.47 | 0.04 |
Age in years | 34.6 (13.1) | 35.1 (12.5) | 1.01 | 0.666 | 1 | 0.99–1.01 | 0.949 |
Sex | | | | | | | |
Male | 113 (36.5) | 61 (32.3) | 1 | | 1 | | |
Female | 197 (63.6) | 128 (67.7) | 1.12 | 0.349 | 1.06 | 0.08–1.28 | 0.559 |
Marital status | | | | | | | |
Married | 150 (48.4) | 110 (58.2) | 1 | | | | |
Single | 133 (42.9) | 65 (34.4) | 0.78 | 0.042 | | | |
Children | 27 (8.7) | 14 (7.4) | 0.81 | 0.349 | | | |
CD4 count | | | | | | | |
≤ 500 | 226 (87.6) | 120 (80.4) | 1 | | | | |
> 500 | 32 (12.4) | 29 (19.5) | 1.37 | 0.04 | | | |
First Viral load | 43982 (35011.1) | 34107.7 (18072.5) | 0.99 | 0.496 | | | |
Initial Regimen | | | | | | | |
Efavirenz-based regimen | 178 (57.4) | 138 (73.0) | 1 | | | | |
Non-Efavirenz-based regimen | 132 (42.6) | 51 (27.0) | 0.64 | 0.001 | | | |
Current regimen | | | | | | | |
NNRTI | 13 (4.2) | 97 (51.3) | 1 | | 1 | | |
Protease Inhibitors(PI) | 285 (91.9) | 29 (15.3) | 0.1 | < 0.001 | 0.11 | 0.08–0.15 | < 0.001 |
DTG-based regimen | 12 (3.9) | 63 (33.3) | 0.95 | 0.429 | 0.96 | 0.85–1.09 | 0.543 |
First detectable viral load | 70203.2 (199420.7) | 90402.5 (289995.8) | 1 | 0.32 | | | |
Days on ART | 1131.3 (1034.2) | 1053.0 (1005.2) | 0.99 | 0.411 | | | |
The Health Care Worker experiences of providing intensive adherence counseling in Kisenyi Health Center IV
In exploring experiences of providing IAC among Health care workers involved grouping of words, sentences and paragraphs of similar message to form meaningful units. Similar meaningful units were condensed to form codes; similar codes were aggregated to form categories which were eventually grouped to form themes. The major themes included; IAC intervention is an effective intervention recommended for PLWH on ART with unsuppressed viral load, patient related factors affect ART adherence and health care system related factors affect adherence.
IAC intervention is an effective recommendation for PLWH on ART with unsuppressed viral load
The findings from health workers’ experiences indicate that IAC is an intervention that has fully been embraced at KHCIV and it was noted as a very useful tool in enabling ART adherence and VL suppression.
“We have to be very sure that the adherence is above 95% or the adherence is good so we continue our adherence counseling reason why I told you we give an allowance of three to six months to conduct intensive adherence counseling. For adults, we are doing the 3 sessions, one month apart. Then at the third session if the adherence is good, we give them a one-month appointment to come back for a repeat viral load”.
” [said a Clinician with 7 years of experience]
They all exhibited a clear understanding of the program as it is provided to those clients with unsuppressed VL (VL > 1000 copies). They said that a patient is considered suppressed with the intervention when the VL is less than 1000 copies/ml. This is determined after the repeat VL after the third session. The main sessions conducted were reported to be 3 but in case the adherence of that particular client is not above 95% then a fourth session is considered. They also said that if poor adherence persists, even after the fourth session, the decision is left to the clinician, otherwise the entire process is repeated, although this rarely happens.
“Actually the third session will be the determinant to go to the fourth one. After the 3rd session if you see that this person has really scored 95%, you can stop on the 3rd one and the fourth visit is just for review and then you forward for VL testing. But if you see that he/she is still in 80 or 70% adherence, then you do the fourth session.” [Said a Counselor with 5 years of experience]
Health care workers felt that this kind of intervention has really done a commendable job in improving adherence levels. Majority said that only about 20%-30% fail to achieve suppression following IAC. And this can majorly be due to several factors which can be both patient and health care related. These are expounded below;
Patient related factors
Non-disclosure
The major patient factor highlighted was non-disclosure. Participants said that most clients, when they learn about their HIV status they start imagining how they would tell others especially their partners. This makes them start taking their ARVs while in hiding and on some occasions it gets tough to hide and they choose not to take it.
“There are situations that come in for a client to tell you that I am not ready for ARVs for example non-disclosure; this is something that comes to them maybe like a shocker to them and so they start imagining you are telling them they are going to take ARVs for life, how am I going to go to my partner, how am I going to keep this medicine. Yes you can give them the medicine because the guidelines say they should take the medicine. It should be noted that all those who fail to disclose, it also gets difficult for them to explain why they would opt for safe sex; this keeps exposing them” [said a Clinician with 7years of experience]
“…then we are having this category of men and women having disclosure issues, maybe a son or daughter fears to tell the father or mother and in that they keep dodging around; today he or she takes, tomorrow he/she doesn’t take; so generally adherence has those dynamics.” [said a Counselor with 5 years of experience].
Social-economic life of the client
It was reported that this is quite key when it comes to adherence. Patients report challenges like lack of food. Some clients do not have jobs and hence cannot afford a living.
Some say that they can’t take medicine on empty stomachs.
“…a mother is going to tell you am not working, we do not have food so I cannot take medicine on an empty stomach; so if the mother is not taking medicine automatically the child will not take medicine if they are also infected and if their issue is food, that is something we might not solve at the facility.” [said a Counselor with 10 years of experience]
“Yes, because they have their other issues. You can do the counseling very well but they go back home some have challenges of food; they say they cannot take this drug when they have not eaten anything.” [said a Counselor with 4 years of experience]
It has been very difficult for the health workers to address some of these challenges of socio economic constraints. They have linked a few clients especially vulnerable children to some projects but these can’t take on all the clients, as they support a limited number.
“But then for the children, Orphans and vulnerable children (OVC) is the program we have here. Children and adolescents that are unsuppressed are linked to this program for support. If it is food, they give them some food but sustainability, the issues of sustainability.” [said a Clinician with 7 years of experience].
We have the OVC program but it only look after children yet there are also adults who are badly off.” [said a Counselor with 4 years of experience].
Other support encouraged by health workers is psychosocial support from family members or relative but this is difficult especially for those who have not disclosed. Other support is also sought from some organizations.
“We are working with some community based organizations(CBOs) but of course they also make things very long, some say we are full like world vision said we are full” [said a counselor with 4 years of experience].
New barriers setting in
Participants reported that some clients, after suppressing, they may come back later with poor adherence and this can be due to new barriers setting in. This can involve some clients relocating and later return after lost to follow-up, peer pressure, getting new partners, gender-based violence (GBV) and others.
“…you are kind of like, you used to do well, what could be the problem! It could be behavior change, it could be nature of work, it could be travelling, it could be distance, and it could be some other things like GBV, so surely it depends. So client is like health worker I used to have a good job, so I used to be well. Others are like they changed marriage and having non-disclosure issues so they are hiding drugs.” [said a Counselor with 10 years of experience].
However, the major barrier that had caused unsuppressed VL during the period when this study was conducted was COVID-19 pandemic outbreak.
“…because people were in lock down, for about two months some were not taking drugs and they were saying that no car was allowed to move and there were no nearby health facilities to some client for drug refills. Many will tell you the lock down got me deep in the village and there is no nearby facility so I was not taking and currently we have got some mothers who are giving birth to positive children because they were not taking drugs during the lock down. [said a Counselor with 4 years of experience].
Health care system related factors
It was reported that determining the readiness of the patient to start ART is very key to ensure that they achieve a sustained adherence throughout their lifetime. And this is done with a checklist to determine a client’s readiness. However, there healthcare-system related factors that influence this.
Counselors’ ability/skill to manage the client’s barriers
It was reported that building rapport with the client is key in solving their ART adherence barriers. If a counselor fails to have a good relationship with the client, then it becomes very difficult for the client to follow their instructions.
“…you know with counseling you need to be closer to the patient as much as possible but as you know government health care workers for some, that is not part of their job; theirs is to come, quickly see patients, give them drugs, and then go. So when it comes to ideal counseling there is a gap there.” [said a Counselor with 10 years of experience].
Additionally, health workers may be transferred and the new health workers may require building trust and relationship with the clients which usually take quite some time. Therefore, in the event a counselor fails to build a good relationship with the client, the adherence barrier will continue affecting the patient.
Client load or workload
The patient-health worker ratio is so low resulting in a health worker attending to many clients a day. This causes fatigue to a health worker as well affecting the clients in terms of the waiting time.
“At the facility level I can say long time waiting for example; some clients come knowing he/she is going to leave early but takes a whole day at the facility.
Another thing I say is manpower; the staff’s ratio to the patients is really not matching, you are a team of twenty and you are looking at a thousand of patients.” [said a Counselor with 5 years of experience].
Due to fatigue among health workers, some clients may not be attended to as expected and this affects adherence because the client’s barrier to adherence will not have been discussed and solved.
“Of course it is important. The very first encounter of a health worker if you find this health worker very tired, their attitude may not be good.” [said a Clinician with 7 years of experience].
Lack of privacy
Due to many clients, the facility environment may not ensure client confidentiality. This causes clients fear to open up in presence of fellow clients. This especially happens during group counseling or when the health workers share a clinical room.
“You know sometimes we share offices like in my room I have a colleague I sit with; the counselors also share offices; when the numbers are many they decide to give a group counseling session forgetting that people have got individual issues. So in that group counseling a client may not open up.” [said a Clinician with 7 years of experience].
“ here we have very big numbers so some clients have stigma; so when they come here and realize that the numbers are too big,they fear to be seen and thereafter start defaulting their appointments.” [said a Counselor with 10 years of experience].
Lack of a multidisciplinary team
Despite the fact that IAC requires a multidisciplinary team involving various cadres right from peer educators, counselors, clinicians, pharmacists, psychologists and family members, this has not been possible and in most cases it’s only one person or two are available to handle a client’s adherence barrier.
“Okay, ideally intensive adherence counseling involves the multidisciplinary team but I have told you that it is hard to collect that team together;. in our setting here the team is supposed to involve a clinician, a counselor, a pharmacist, an expert client, a family member and a support group.. But bringing these persons together to talk to this client is something hard and some are not available.” [said a Clinician with 7 years of experience].
This means that the workload would be much and one might not be trained enough to do the work of the other. This leaves the patient with scanty information.
Other barriers
These include drug side effects and language barrier. Despite not vividly highlighted, it was reported that a few clients may fail to contain the side effects and hence opt for drug holidays. Additionally, the location of KHCIV has many refugees who only speak their own languages and this affect the communication with health workers. The other health care related barriers included drug resistance, drug stock-out, and results turn-around time.
Facilitators of IAC provision at KHCIV
Use of peer educators, this has enabled to reduce workload of health care workers “You know us health workers we tend to think that these peers or expert clients will not give the right information but if these people are empowered, they give that starter information before they proceed to the counselor because this is a person who has been in the same situation before so they will educate this client basing on what they have gone through.” [said a Clinician with 7 years of experience].
However, there are some things missing in the use of peer educators strategy at KHCIV such as lack of adequate training and mentorship “So if we engage these peers, give them the training and mentorship, they can do the counseling very well; so that is what is missing here.” [said a Counselor with 10 years of experience].
Assigning special clinic days and sessions to special groups or clients
In order to reduce the workload and provide more time to special groups of clients. There is a need to have less numbers at a time so that special clients with adherence difficulties are given more time .At KHCIV, special clinic day and session strategy has been developed and utilized.
“Tuesday is for those with unsuppressed viral load. So when these patients come in we let them have a group session with expert client first; then a clinician chip later and there after they are sent to the counselor. Pregnant and breastfeeding clients also have their own sessions; clients also have their family support sessions where they are given some information before they go to the counselor.” [Said a Clinician with 7 years of experience]
Improving IAC provision at KHCIV
In order to improve the implementation of the IAC and its performance, health workers suggested a few things to fix.
Intensifying the IAC
Majority of the health workers agreed that there is need to intensify the IAC intervention, they said that this could be done by improving the multidisciplinary nature of the IAC team by availing more health care workers or or professional cadres.
The other way of improving IAC is by increasing the number of sessions beyond three. It was reported that increasing sessions allows continuous counseling and health education talks which provide the ability to continuously identify new barriers.
“…we maybe probably need to add things like maybe the sessions, sometimes you feel like maybe the three sessions are not be enough depending on a particular client forexample the adolescents.[said a Counselor with 10 years of experience].