Despite significant progress in lowering HIV infection rates and AIDS-related mortality thanks to prevention programs and the use of highly active antiretroviral drugs (HAART), sub-Saharan Africa still has the highest HIV prevalence rate in the world at 67 percent, accounting for 72 percent of all HIV-related deaths globally. The patient's level of adherence— which includes keeping appointment times, taking drugs as directed, and not skipping out on therapy—determines how well these antiretrovirals work for a certain patient. This study's objectives were to assess the level of antiretroviral therapy adherence among HIV-positive individuals (PLHIV) at Korle-Bu Teaching Hospital and to identify the factors that predict adherence to antiretroviral therapy. A cross-sectional study design was used for the research. Using standardized questionnaires derived from various publications, patient records were examined, and patients were questioned about their level of adherence. After data was exported to Excel, STATA16.0 was used to analyze it. All variables were summarized using frequency distribution. The association between the variables was examined using the chi square. To ascertain the degree of association between the outcome and exposure variables at a 95% confidence level, both univariate and multivariate logistic regression analysis were used. The adherence level was found to be sub- optimal (65.7%). It was discovered that the past week's and six-months' worth of adherence was 93.7% and 80% respectively. The factors which showed association included traditional medicine use (AOR=2.54, 95%CI=1.02-6.33, p=0.044) and alcohol use (AOR=2.45, 95%CI=1.04-5.75, p=0.039). Healthcare practitioners can greatly increase adherence in this population by educating them about the dangers of taking traditional medicines and alcohol at the same time.

Keywords: Human immunodeficiency virus, Acquired Immune Deficiency Syndrome, Antiretrovirals, highly active antiretroviral therapy, People living with HIV, Korle-Bu Teaching Hospital, Adherence

Human immunodeficiency virus (HIV) infection remains a major global public health concern, having affected around 77.3 million individuals worldwide and resulting in 35.4 million deaths since its discovery in the early 1980s (Maseko & Masuku, 2017). Although significant progress has been made in reducing HIV infection rates and AIDS-related mortality through prevention initiatives and the use of highly active antiretroviral medicines (HAART), about 67% of the world's HIV prevalence rate is still concentrated in Sub-Saharan Africa, accounting for 72% of HIV-related deaths worldwide (Maseko & Masuku, 2017).

The introduction of highly active antiretroviral therapy (HAART) has transformed HIV from a highly fatal disease into a chronic condition, significantly increasing life expectancy and reducing HIV transmission rates (Bezabhe et al., 2016; Bukenya et al., 2019). However, successful HIV management and control largely depend on optimum adherence to antiretroviral therapy. Adherence is defined as a patient's ability to take each anti-HIV medication correctly, at the right time, and exactly as prescribed (Pefura-Yone et al., 2013). Unfortunately, achieving high levels of adherence in Sub-Saharan African nations has proven challenging, and non-adherence poses significant risks to both the individual's health and public health (Yu et al., 2018).

Despite significant efforts to combat HIV, achieving the UNAIDS HIV treatment targets by 2030 (95-95-95) remains a challenge for Ghana. Current data indicates that the country has achieved only 71-99-79 (71% know their HIV status, 99% on ART, and 79% virally suppressed) (UNAIDS 2025 AIDS Target).  Optimum adherence to ART is crucial for achieving viral suppression, and studies in Ghana have revealed suboptimal adherence rates ranging from 62.2% to 75%. Causes of non-adherence include treatment fatigue, pill burden, alcohol consumption, side effects of ARVs, and forgetfulness (Hailu Chare, 2018; Obirikorang et al., 2013; Reda & Biadgilign, 2012).

The study aimed to investigate the level of adherence to antiretroviral therapy (ART) among people living with HIV (PLHIV) at the Korle-Bu Teaching Hospital. The research objectives included assessing the adherence level and identifying the factors that contribute to adherence in this population. The study aimed to determine socio-demographic, patient-related, health facility- related, and disease- and regimen-related factors that influence adherence to ART. Through the understanding of these factors, the study sought to provide valuable insights into the challenges faced by PLHIV in this setting and inform targeted interventions to enhance adherence and improve HIV treatment outcomes.

Study design

The study used an analytical purposive and facility-based study designed to determine adherence to ART in people living with HIV (PLHIV) at the Korle-Bu Teaching Hospital (KBTH).

Setting

The study area was the Adherence Counselling Unit, Internal Medicine Department Korle-Bu Teaching Hospital (KBTH), at Korle Gonno in the Ablekuma South Sub-Metro District, Accra- Ghana.

Study population and recruitment

This study included all HIV-seropositive patients who attended clinic at the KBTH, 18 years and older and had been on ARVs for at least 3 months. Patients who were critically ill and documented mental illness were excluded from the study.

Sampling procedure

Purposive sampling was used as the sample technique. This required including every person who was eligible to participate in the study and met the criteria for participation. A sample size of 244 participants was calculated accounting for 20% non-response rate.

N= Z²p (1-p)/MOE²

N= sample size; p= prevalence in similar study; Z= confidence interval

N= (1.96C1.96) C0.844 (1-0.844) / (0.05C0.05)

N= 203

Therefore, the sample size for this study was 244 participants.

This was calculated based on the level of adherence of 84.4% from a study conducted by Ankrah et al. (2015) which looked at prevalence and treatment change, at the Fevers unit of KBTH.

Data collection

Structured questionnaires were used to collect data from recruited participants. Data on socio- demographic characteristics, frequency of adherences, history of hospitalization, presence of co- morbidities, disclosure status to partner and health-facility-related factors were obtained. Data on information on the duration of HIV infection, type of ART regimen and duration of ART, history of hospitalization and presence of co-morbidities were confirmed from patient records. Assistance was obtained from two staff of the hospital to help retrieve records and collect data. They were trained by the researcher on data collection tools and processes and ethical considerations.

Data analysis

Microsoft Excel 2013 and Stata IC version 16 were used for data analysis. Mean and proportion were used to summarize continuous variables, while bar charts, pie charts, and frequency distribution tables were used for categorical variables. Pearson's chi-square (χ2) test was used to measure the association between exposure and outcome variables at 0.05 significance level. Crude and Adjusted odds ratios were calculated to assess the associations. Logistic regression, including univariate and multivariate analyses, was used to determine the strength of association between exposure and outcome variables.

Ethics

The study obtained ethical approval from the Institutional Review Board of the Korle-Bu Teaching Hospital (KBTH-IRB 000235/2022) and sought permission and approval from the Head, Adherence Counselling Unit of the same Hospital. The purpose of the study was explained to participants in languages they understand. Participants’ right to partake or not to partake was duly explained. No benefit or sanction would be administered to anyone, reiterating the study was voluntary. And assurance of confidentiality, privacy and data protection. Their informed consent was sought afterwards. Data obtained was accessible only to research assistants and the principal investigator and patient initials were used in data collection instead of names for anonymity. Researchers involved in the study were blinded to ensure confidentiality and anonymity. Data will be made available upon reasonable request from the corresponding author.

Study design

The study used an analytical purposive and facility-based study designed to determine adherence to ART in people living with HIV (PLHIV) at the Korle-Bu Teaching Hospital (KBTH).

Setting

The study area was the Adherence Counselling Unit, Internal Medicine Department Korle-Bu Teaching Hospital (KBTH), at Korle Gonno in the Ablekuma South Sub-Metro District, Accra- Ghana.

Study population and recruitment

This study included all HIV-seropositive patients who attended clinic at the KBTH, 18 years and older and had been on ARVs for at least 3 months. Patients who were critically ill and documented mental illness were excluded from the study.

Sampling procedure

Purposive sampling was used as the sample technique. This required including every person who was eligible to participate in the study and met the criteria for participation. A sample size of 244 participants was calculated accounting for 20% non-response rate.

N= Z²p (1-p)/MOE²

N= sample size; p= prevalence in similar study; Z= confidence interval

N= (1.96C1.96) C0.844 (1-0.844) / (0.05C0.05)

N= 203

Therefore, the sample size for this study was 244 participants.

This was calculated based on the level of adherence of 84.4% from a study conducted by Ankrah et al. (2015) which looked at prevalence and treatment change, at the Fevers unit of KBTH.

Data collection

Structured questionnaires were used to collect data from recruited participants. Data on socio- demographic characteristics, frequency of adherences, history of hospitalization, presence of co- morbidities, disclosure status to partner and health-facility-related factors were obtained. Data on information on the duration of HIV infection, type of ART regimen and duration of ART, history of hospitalization and presence of co-morbidities were confirmed from patient records. Assistance was obtained from two staff of the hospital to help retrieve records and collect data. They were trained by the researcher on data collection tools and processes and ethical considerations.

Data analysis

Microsoft Excel 2013 and Stata IC version 16 were used for data analysis. Mean and proportion were used to summarize continuous variables, while bar charts, pie charts, and frequency distribution tables were used for categorical variables. Pearson's chi-square (χ2) test was used to measure the association between exposure and outcome variables at 0.05 significance level. Crude and Adjusted odds ratios were calculated to assess the associations. Logistic regression, including univariate and multivariate analyses, was used to determine the strength of association between exposure and outcome variables.

Ethics

The study obtained ethical approval from the Institutional Review Board of the Korle-Bu Teaching Hospital (KBTH-IRB 000235/2022) and sought permission and approval from the Head, Adherence Counselling Unit of the same Hospital. The purpose of the study was explained to participants in languages they understand. Participants’ right to partake or not to partake was duly explained. No benefit or sanction would be administered to anyone, reiterating the study was voluntary. And assurance of confidentiality, privacy and data protection. Their informed consent was sought afterwards. Data obtained was accessible only to research assistants and the principal investigator and patient initials were used in data collection instead of names for anonymity. Researchers involved in the study were blinded to ensure confidentiality and anonymity. Data will be made available upon reasonable request from the corresponding author.

This study found a suboptimal adherence level of 65.7% among the study participants. This is comparable to studies conducted by Obirikorang et al in Ghana and Haliu in Southern Ethiopia, which revealed an adherence level of 62.2% and 60% respectively (Hailu Chare, 2018; Obirikorang et al., 2013). However, the adherence level from this study contrasts with those of 84.4% and 97% reported by Ankrah et al., (2015) and Adam et al.,(2015) respectively.

The study had more female participants (77.4%) than males which can be attributed to the prompt health-seeking behaviour of women. The anatomy of the female reproductive organ makes them more susceptible to the infection and could also account for the above observation.

Older persons aged 45 years and above were more adherent to ART compared to the other age groups. Similarly, older HIV-positive individuals had a decreased risk of non-adherence to ART compared to their younger counterparts in past studies (Banagi et al., 2016; Ghidei et al, 2013; Kanyoni et al, 2018). This study found a weak association between income and ART adherence, contrary to the positive association reported between income level and ART adherence other studies(Hailu Chare, 2018; Rachlis et al., 2011). Transportation costs for scheduled hospital appointments and additional prescription costs for comorbidities are the main patient expenses and these are dependent on the patient’s income level.

Patient-related factors

Patients seemed more adherent to once-daily combination pills than multiple/frequent dosing regimens, although this study found no association between pill burden and adherence. This study found that majority of the patients did not feel burdened by their pills and this is consistent with a recent study (Adam et al., 2022).

There was no correlation between adherence and partner disclosure status as 51.5 percent of the study participants had told their partners about their sexual orientation. Studies done in Kenya (Kanyoni et al., 2018; Omanje et al., 2015) showed similar results. This finding suggests that many individuals are likely to expose themselves and their partners to the infection when they are not open about their HIV status.

Contrary to the tendency for non-adherence when patients begin to feel better after taking medications, this study showed an increase in adherence in participants who thought highly of their wellbeing. This could be due to prior and intermittent counseling sessions and the patients realizing the benefits of the medications.

Stigma remains one of the barriers to adherence. Similarly, Haliu and Tran found an association between stigma and adherence to ART (Hailu Chare, 2018; Tran et al., 2013). Self-stigma and feeling hopeless may, however, demoralize patients and reduce adherence levels.

Consistent with a study conducted by Venkatesh et al.  (Venkatesh et al., 2010), this study found an association between alcohol use and non-adherence to therapy. A similar study by Kader et al also revealed that alcohol consumption is associated with poor adherence to ARVs (Kader et al., 2015).

It has been reported that for some patients, concurrent or sole use of traditional medicines results in better health outcomes compared to the use of only ARTs (Hughes et al., 2012). In a study by Lubinga et al, concurrent use of traditional medicine with ART was found to be associated adherence to ART  (Lubinga et al., 2012). However, traditional medicines have been found to decrease adherence in PLHIV and cause severe drug interactions which may either cause therapeutic failure or toxicity (Seden et al., 2015).

While those hiding their identity for fear of stigma may find longer travel distances advantageous, patients with shorter travel distances are more likely to adhere to therapy. A study by Bilinski et al. found an association between travel distances and ART adherence, contrary to the findings from this study.(Bilinski et al., 2017b)

Disease-related factors

Hospitalization resulting from the HIV infection with associated discomfort has been found to increase adherence. In a study involving HIV positive patients, it was found that the adherence behavior mastered for HIV may be transferred to self-management of other comorbid conditions (Weiss et al., 2016). However, no association was found between hospitalization and presence of comorbidities and adherence in this study.

Medication-related factors

People with HIV are known to be ART adherent on the onset, but gradually lag behind in the adherence to the therapy as their health and quality of life advance (Banagi et al., 2016). However, in this study individuals who were on ART for less than a year demonstrated worse adherence than those who had been receiving ART for more than a year. Although there was no correlation between adherence and regimen type, patients on integrase inhibitor-based regimens adhered to therapy more frequently than those on NNRTI-based regimens. This could be a result of the adverse effects associated with the NNRTI-based regimens.

Healthcare related factors

The level of adherence in this study was higher among those who answered in the affirmative to their HCPs being friendly. Studies have shown that a good relationship fosters confidentiality between patients and their HCPs, thus adherence is dependent on the relationship between HCPs and patients. Although there was no association between calls and adherence, it has been found that reminders through phone calls improve adherence (Dzansi et al., 2020).

Implications for policy, practice and future research

The findings from this study aims to identify the barriers to adherence in PLHIV. This could be taken up by the management of the adherence counselling unit, Ghana AIDS Commission and National AIDS/STI Control Program.

Owing to its importance as an issue of concern for the country, researchers need to expand their scope to include determinants of concurrent use of traditional medicines and ARTs. Addressing these concerns is crucial for the campaign against HIV/AIDS to fulfil the Sustainable Development Goals' SDG Target 3.3 aims to end the AIDS epidemic by 2030.

Study limitations

Social desirability bias could have impacted this study as participants may have exaggerated their medication adherence to impress the researchers. Also, the responses of some participants may have been influenced by recall bias due to cross sectional nature of the study design. However, these were minimized through thorough training of interviewers.

The study revealed a sub-optimal level of adherence (i.e. 65.7%) among PHLIV attending clinic at the KBTH. Alcohol consumption and traditional medicine, however, were associated negatively with adherence to ART. There is, therefore, the need to work harder towards improving the level of adherence to ART in order to reduce the rate of new infections.

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Our sincerest appreciation goes to Pharm Priscilla Ekpaele, Dr. Francisca Zigah, Pharm Selassie Ahiati and staff of the adherence counselling unit of KBTH for their immense assistance. All authors are duly appreciated for their diligence and hard work in achieving this feat.