Factors associated with antiretroviral therapy default in the 34-Military Hospital, Sierra Leone, 2017-2020

Henry Bangura¹, Fatmata Bangura¹, Jean Leonard Hakizimana², Adel Hussein Elduma^2,&, Gebrekrstos Negash Gebru²

 

¹Ministry of Health, Freetown, Sierra Leone, ²Sierra Leone Field Epidemiology Training Program, Freetown, Sierra Leone

 

 

^&Corresponding author
Adel Hussein Elduma, Sierra Leone Field Epidemiology Training Program, EOC Wilkinson Road, Freetown, Sierra Leone.

 

 

 

 

The human immunodeficiency virus (HIV) continues to pose a global public health problem. Globally, 38.4 million people were living with HIV in 2021 [1]. In Sierra Leone, about 78,000 people lived with HIV in 2019, and only 33,000 (43%) were on antiretroviral therapy (ART) [2]. ART, a therapy that suppresses the human immunodeficiency virus to undetectable levels, allows people living with HIV/AIDS (PLWHA) to have a better quality of life. However, ART must be taken for life. The World Health Organization (WHO) set a global target of 95-95-95 to halt the HIV pandemic by 2025. The 95-95-95 translates to 95% of persons living with HIV knowing their HIV status, 95% of people who know their HIV-positive status access treatment, and 95% of people on treatment have suppressed human immunodeficiency virus [3]. In Sierra Leone, the Government and health development partners invested in monitoring ART as part of their strategy to reach the target of 95-95-95 by 2025. However, HIV/AIDS continues to be a public health problem due to ongoing transmission and increasing prevalence. Likewise, ART comes with many challenges including access to treatment and defaulting from treatment which makes HIV control difficult [4].

 

In antiretroviral treatment, there is strong evidence that early ART initiation leads to better clinical outcomes in people living with HIV [5]. Furthermore, safer, and more effective ARV drugs are becoming available, and newer drugs (integrase inhibitors) are becoming available for low- and middle-income countries. Most countries have moved or are moving to provide lifelong ART regardless of CD4 cell count for all pregnant and breastfeeding women, and many are moving to implement viral load tests as the preferred means of monitoring people taking ART.

 

Using ART has an obvious effect on reducing the viral load among people who adhere to the treatment [6]. However, defaulting from ART is a challenge in controlling the HIV pandemic, especially in Sub-Saharan Africa. Defaulters increase the risk of developing drug resistance and treatment failure. Sub-Saharan Africa documented difficulties in retaining patients in care for life [7, 8]. Studies conducted in Zimbabwe, Ethiopia, and South Africa have shown that most ART programs in Sub-Saharan Africa retain only 60% of patients on treatment at the end of 2 years [4, 9,10].

 

Anecdotal reports showed that ART clients at the 34 Military Hospital HIV/AIDS Clinic do not adhere to treatment. In addition, the prevalence of ART defaulters has not been estimated to know the default rate in the country in general and at the 34 Military Hospital in particular. Additionally, there is limited information on ART defaulting. However, a qualitative study conducted in Sierra Leone among people living with HIV identified family support, having informal caregivers, and receiving free ART medicine as factors influencing adherence to ART [2].

 

This study was conducted to describe the demographic and clinical characteristics of ART clients, determine the proportion of ART defaulters, and determine factors associated with ART defaulting at the 34 military hospital in Sierra Leone. The results of this project will help the Ministry of Health and Sanitation to develop strategies to reduce the proportion of defaulters and improve the ART program in Sierra Leone.

 

 

Study design and study area

 

We conducted a cross-sectional study using secondary data analysis of HIV/AIDS patients at the 34- Military Hospital in Sierra Leone. The hospital is located in Freetown, Western Area Urban District. This hospital is a teaching and general hospital that provides care to HIV patients coming from different parts of the country.

 

Study population

 

In Sierra Leone, clinicians offer an HIV screening test to all pregnant women who attend antenatal care and to all clinically HIV-suspected clients. Those who test positive have a confirmatory laboratory test done. All HIV-positive clients are referred and enrolled in ART. All HIV/AIDS patients enrolled in ART from 2017-2020 were considered as the study population for this study. It cumulatively included all clients who were on ART during the study period. A defaulter was defined as any ART client who missed at least two consecutive monthly clinic appointments between January 1, 2017, and December 31, 2020. ART clients who were registered and taking ART for the last six months, and those aged 15 years and above were included in the study.

 

Sampling

 

We recruited all HIV/AIDS patients on ART who visited the hospital from January 1, 2017, to December 31, 2020. The defaulters were identified in the clinic registers and followed -up to know the reasons for defaulting. The cumulative ART clients in 2017 were 736, with 310 defaulters, 2018 had 906, with 380 defaulters, 2019 had 1061 with 452 defaulters, and 2020 had 1202 with 512 defaulters. So, a total of 1202 ART clients were included in the analysis during the study period (Figure 1).

 

Data collection

 

A structured questionnaire was used to collect data from the HIV/AIDS treatment registries. These registries included in-patient ART clinical registers, outpatient HIV/AIDS screening registry, Prevention of Mother-To-Child Transmission (PMTCT) register, viral load monitoring chart, and HIV/AIDS treatment registers. Data on ART defaulting, and demographic and clinical characteristics were collected from these registers. Key variables covering ART defaulting, demographics, and clinical were collected including age, sex, marital status, occupation, ART regimen, treatment outcome, TB/HIV co-infection, points of ART entry, and reasons for defaulting were analyzed and presented in tables. The researcher called clients directly to get the information. In situations where clients were not accessible, that is, if lost to follow-up, died, or changed contact address, their proxies (persons authorized by ART clients to provide information related to their treatment) were interviewed. Proxies were approached using the information provided during the first enrolment of the clients. Data was collected from proxies either by phone call or home visit for those who were not accessible through the phone call. Data on health status, treatment outcomes of the clients, and the reasons for defaulting were obtained in this process. Data collected from proxies was combined with the data collected from registries for each client.

 

Data analysis

 

Extracted data were cleaned and prepared for analysis using Excel software. Epi Info 7.7 software was used to compute the frequency and proportion of demographic and clinical characteristics of ART defaulters. A forward stepwise approach was used to assess the association between dependent and independent variables to build the logistic regression model. This approach includes fitting each variable separately using a categorical scale. The simple logistic regression was built based on the existing literature, and clinical and biological variable specifications. We fitted the simple logistic regression model for each possible risk factor. We used a significant level of 0.2 to provide the largest possible model which will be initially considered. The multiple logistic regression model included all variables retained in the univariate analysis. Variables included in the multiple logistic regression were ART regimen, marital status, occupation, point of entry for ART, WHO clinical stage of enrollment, TB/HIV coinfection, and treatment outcome. We calculated the adjusted odds ratios (aOR) and their 95% Confidence Interval (CI) to identify factors associated with defaulters, and variables that scored p< 0.05 were considered as statistically significant at multiple logistic regression.

 

Ethical Considerations

 

The study was approved by the Internal Review Board of the Joint Medical Unit of the Republic of Sierra Leone Armed Forces (Joint Medical Unit approval letter, number 2651, Dated January5, 2017. No personally identifiable information was disclosed to any party except the main investigator since only codes were used to represent the identity of the clients. Verbal informed consent was obtained before enrolling any study subject.

 

 

We enrolled 1202 clients who were on ART at the 34-military hospital from January 1, 2017, to December 31, 2020. There were 645 (53.6%) women and most ART patients, 789 (65.6%) were 35 years and older. The age groups 25 - 34 and 35 years and over accounted for 94.9 % of the ART clients. Of the total study respondents, 297 (14.7%) were security officers. More than half of the study participants were married 704 (58.6%), 395 (32.7%) were single, and 93 (8.6%) were divorced or widowed (Table 1). Most ART clients, 901 (75%), were enrolled in the treatment through routine clinical diagnosis, with 124 (10.3%) coming from the TB clinic referral system. In addition, 55 (4.6 %) were referred from the prevention mother-to-child transmission (PMTCT) clinic, and 33 (2.7 %) were enrolled either through voluntary confidential counseling and testing (VCCT) or referred from other health facilities.

 

A total of 934 (77.7 %) ART patients were at stage two or three of infection, 174 (14.5 %) were in stage four or five and only 94 (7.8%) were in stage one. A total of 1185 (98.6%) of the ART clients received the first-line ART regimen, while 17 (1.4%) received second-line treatment. ART clients who were co-infected with TB during the study period were 251 (20.9%). Most of the study participants, 1077 (97.9 %) were alive and continuing treatment (Table 2).

 

A total of 512(43%) of the 1202 ART clients defaulted over the study period (Table 3). shows the reasons why clients defaulted, with 174 (34.2%) stating they opted for traditional medicine and 51 (10%) defaulted because they thought they were well, 10% (50/512) of ART clients defaulted because they followed their church pastor's advice, while 7% (38/512) defaulted due to fear of disclosing their status to their spouses. Also, a lack of family assistance 6% (30/512), a lack of funds for transportation 5% (25/512, and a lack of food at home 3% (14/512) contributed to 6% (30/512), 5% 25/512), and 3% 14/512 of defaults, respectively.

 

Multivariate analysis

 

For ART patients receiving second-line therapy, the odds of defaulting were 7 (aOR = 7.1, 95%CI = 2.4-22.1) compared to those on first line drugs. Healthcare workers and motorbike riders/mechanics had odds of default of aOR = 2.8 (CI = 1.2-6.3) and aOR = 0.3 (CI = 0.1-0.6), respectively. For ART clients from HIV referral clinics the odds of defaulting were aOR = 4.5, 95% CI =1.8-11.3), ART clients referred from the TB clinic had odds of default of aOR = 0.2, 95% CI =0.1- 0.4). The TB/HIV co-infection had odds of default (aOR = 57.2 95% CI =31.6-103.7). The odds of defaulting were aOR = 3.7 (95% CI =1.4-9.8) among dead ART clients compared to those who were alive. Compared to divorced clients the odds of defaulting among the married were (aOR = 0.13 95% CI =0.05-0.35), the single (aOR = 0.06 95% CI = 0.02-0.17), and widowed (0.04 95% CI = 0.01-0.15). In addition, ART clients at clinical stages four and two are less likely to default to ART treatment as compared with stage 1 (aOR = 0.15, 95% CI = 0.06- 0.39), (aOR=0.84 95%CI=0.41-0.74) respectively (Table 4).

 

 

This study reported a high proportion of ART default (43%) in the 34-Military Hospital in Sierra Leone. We identified both risk and protective factors of ART default among HIV clients. The factors associated with an increased likelihood of ART default were taking second-line ART drugs, being referred from an HIV clinic, being a health care worker, and an HIV/TB co-infection. The protective factors were being married, single or widowed compared to divorced; motor drivers/mechanics, being referred from a TB clinic, and HIV clinical stage 2 and 4 at treatment initiation. The high ART default rate in this study was similar to the Zambia one (58%) [11]. However, the default rate in Ethiopia (13%) was lower than our findings [12], probably because of the better quality of HIV care in Ethiopia compared to Sierra Leone.

 

Divorced clients were at increased risk of defaulting ART compared to clients in other marital status (married, single, and widowed). This might be because divorced clients did not receive the necessary support provided by their partners. A similar finding was reported by a study conducted in Ethiopia, where being a divorced woman was associated with HIV treatment discontinuation [13]. A study in India disagrees with this finding[14].

 

In this study, clients in the second-line treatment had a higher rate of defaulting. The justification for this result is non-adherence to medication. This could be due to the side effects that accompany a long treatment regimen. Additionally, toxicity associated with certain ART drugs (such as lopinavir and didanosine), may contribute to the client´s lack of ART adherence [15]. A similar finding was reported in a study conducted in South Africa on the toxicity associated with certain ART drugs where patients with virological failure on second-line ART were identified [16].

 

Despite the low rate of TB / HIV co-infection among ART clients, the default rate for this group was very high. These findings are in line with an earlier study conducted in Ethiopia that showed a strong association between discontinuation from ART and having TB/HIV co-infection [17]. TB, as a disease, allows the progression of HIV disease to an advanced stage thus obliging patients to follow a regular treatment intake [18]. Moreover, clients who were co-infected with TB and HIV are more likely to default from ART because of the profound impact of TB on ART outcomes, as TB influences the progression of HIV/AIDS and its treatment. In addition, both HIV and TB pill burdens have an impact on an individual´s treatment and have been shown to have a physical impact on clients´ mobility. Some TB/HIV co-infected patients stated that they prefer to take anti-TB drugs rather than ART because they know there is no cure for HIV/AIDS [19]. Clients who had been referred from a TB clinic were less likely to default on ART. This could be likely due to good treatment adherence experience among TB patients which could result in better adherence to ART. study conducted in Ethiopia revealed that TB patients believed that their body adapted to the TB treatment within time and it will make it easier to adapt to the ART [20]. Based on our findings, health workers have a higher odds of ART defaulting. The reason for ART defaulting among health workers could likely be due to stigma and fear of disclosing their HIV status, particularly to their peers. Health workers witness stigma associated with HIV when dealing with HIV patients during their duties at hospitals or healthcare centers [21]. Additionally, motorbike riders/mechanics are less likely to default ART. This could likely be due to the reason that motorbike riders/mechanics did not have problem in accessing ART centers. Furthermore, this group had social media platform for sharing information among them. Our findings revealed that ART defaulted clients were more likely to die compared with non-defaulters. This could likely be due to the clinical consequences as a result of not receiving the treatment.

 

Another cause of ART default is stigma and its associated rejection in the community, which remains a daily problem for people living with HIV in Sierra Leone. Our study showed that ART defaulters feared community stigma, where considerable ART defaulters did not disclose their HIV status to family members. Previous research identified fear of rejection and social isolation as reasons for discontinuation of care [7]. Furthermore, many studies reported that stigma and fear of isolation were identified as major barriers to adherence to treatment. The findings of our study suggest that strategies are needed to empower patients to overcome these difficulties, even in areas with HIV prevalence. Also, fear of disclosure of status to spouses or family members can be attributed to fear of breakdown of marriage, rejection, discrimination, and loss of employment, especially for women [22].

 

ART clients at stage four of HIV infection had lower rate of defaulting compared with first stage. HIV patients at stage four suffer from severe symptoms which lead them to seek ART services. ART clients at stage two had lower rate of defaulting compared to first stage. Having low rate of defaulting will improve the treatment outcome of clients in stage two and then better prognosis [23]. Seeking traditional medicine or spiritual healing was very high among ART defaulters. It was clear that traditional medicine was becoming an alternative option for HIV patients seeking treatment [7]. This may be due to the belief that HIV is a disease that occurs due to a curse or hatred by an enemy. In addition, some clients on ART lose their confidence since ART can cure HIV and then prefer to seek traditional medicine and spiritual healing. Study conducted by Ndou-Mammbona AA found that traditional healing has both negative and positive effects on HIV and AIDS management. The positive effects include the treatment of some opportunistic infections such as diarrhea. The negative effects involve bleeding, anemia, dehydration, and electrolyte imbalances. Studies conducted in South Africa [24]and Mozambique [25] found that the HIV-related practices of traditional healers, such as the reuse of razors, probably increase the risk for both HIV-infected and uninfected persons.

 

Studies have shown that people´s behaviors, advice, and beliefs determine the health behavior considered as a main pathway for individual decision-making and reflect localized norms and levels of support within an individual social network [26, 27]. Furthermore, the strength of social influence could disrupt treatment adherence and can cause the complete discontinuation of the treatment program [28]. Several studies have also demonstrated how people adjust their behavior according to their immediate social environment, which also affects their health-seeking behaviors [29-31]. One factor that led to defaulting was the lack of transportation money. Studies have found that factors that influence patient retention in care include structural, social, health system, and economy-related factors[14, 32].

 

When social support is affected by voluntary disclosure of HIV status, individuals abandon treatment as a protective mechanism. HIV/AIDS-related stigma is a serious obstacle to the long-term retention of ART. HIV/AIDS-related stigma can exist at individual, family, and community levels and is characterized by rejection, denial, and social distance, as many people still associate HIV/AIDS with moral decadence and promiscuity [7, 29].

 

Limitations of the study

 

Since we used a self-report adherence measurement tool, some of the participants could have been dishonest during their reporting introducing an information bias. Since the study used secondary data, there were some missing variables which might have affected the findings of the study. Level of viral load and CD4 count were not included as variables to determine response to ART. We were unable to assess the relationship between adherence to ART treatment and disease progression.

 

 

ART default was high compared to other studies.While most of the ART clients continued with their treatment because of the associated benefits, many of the defaulters were using traditional medicine, others thought they were well, some feared revealing their HIV status to their spouses, and stigmatization in their communities. We recommend strengthening personal, community, and family support and health system support that will help PLHIV to continue ART, improve access to HIV care, reduce loss to treatment follow-up. We also recommend mass sensitization on the benefits of adhering to treatment, the consequences of defaulting, and the importance of accessing and seeking early treatment.

 

 

The authors declare no competing of interest.

 

 

Conceptualization and design: Henary Bangura, Fatmata Bangura, Jean Leonard Hakizimana, Gebrekrstos Negash Gebru. Data Collection: Henary Bangura, Fatmata Bangura, Analysis, and Interpretation: Adel Hussein Elduma, Jean Leonard Hakizimana; Drafting and Review of Manuscript Adel Hussein Elduma, Jean Leonard Hakizimana, Gebrekrstos Negash Gebru. All the authors reviewed and approved the final manuscript.

 

 

Table 1: Demographic characteristics of people living with HIV attending ART clinic the Thirty-four Military Hospital, Freetown, Sierra Leone, 2017-2020, N= 1202.

Table 2: Clinical characteristics of people living with HIV attending ART clinic at the Thirty-four Military hospital, Freetown, Sierra Leone, from January 2017 to December 2020, N=1202.

Table 3: Reasons for ART defaulting at the Thirty-four Military hospital, Freetown, Sierra Leone, Jan, 2017 to Dec, 2020, N= 512.

Table 4: Factors associated with ART defaulting at the Thirty-four Military hospital, Freetown, Sierra Leone, Jan, 2017 to Dec, 2020.

Figure 1: Flow chart showing the recruitment of the ART clients and the ART defaulters 2017-2020 in the Thirty-four Military Hospital, Freetown Sierra Leone.

 

 

1. World Health Organization. HIV [Internet]. Geveva (Switzerland): World Health Organization; c2024[cited 2024 Dec 13].


2. Lahai M, Theobald S, Wurie HR, Lakoh S, Erah PO, Samai M, Raven J.Factors influencing adherence to antiretroviral therapy from the experience of people living with HIV and their healthcare providers in Sierra Leone: a qualitative study . BMC Health Serv Res [Internet]. 2022 Nov 8 [cited 2024 Dec 13];22(1):1327. https://doi.org/10.1186/s12913-022-08606-x PubMed | Google Scholar


3. UNAIDS. The path that ends AIDS: UNAIDS Global AIDS Update 2023[Internet]. Geneva (Switzerland): UNAIDS; 2023 Jul 13[cited 2024 Dec 14]. 193 p. Download 2023-unaids-global-aids-update_en.pdf.


4. Wandeler G, Keiser O, Pfeiffer K, Pestilli S, Fritz C, Labhardt ND, Mbofana F, Mudyiradima R, Emmel J, Egger M, Ehmer J.Outcomes of antiretroviral treatment programs in rural Southern Africa. JAIDS Journal of Acquired Immune Deficiency Syndromes [Internet]. 2012 Feb 1 [cited 2024 Dec 13];59(2):e9-16. https://doi.org/10.1097/qai.0b013e31823edb6a PubMed | Google Scholar


5. Takarinda KC, Harries AD, Srinath S, Mutasa-Apollo T, Sandy C, Mugurungi O. Treatment outcomes of new adult tuberculosis patients in relation to HIV status in Zimbabwe . Public Health Action [Internet]. 2011 Dec 1 [cited 2024 Dec 13];1(2):34-9. https://doi.org/10.5588/pha.11.0001 Download s4.pdf. PubMed | Google Scholar


6. Costa JDO, Ceccato MDGB, Silveira MR, Bonolo PDF, Reis EA, Acurcio FDA.Effectiveness of antiretroviral therapy in the single-tablet regimen era. Rev saúde pública [Internet]. 2018 Nov 12 [cited 2024 Dec 13];52:87. English, Portuguese. https://doi.org/10.11606/s1518-8787.2018052000399 Download zeluiz,+0034-8910-rsp-52-87872018052000399.pdf. PubMed | Google Scholar


7. McGuire M, Munyenyembe T, Szumilin E, Heinzelmann A, Le Paih M, Bouithy N, Pujades–Rodríguez M. Vital status of pre-ART and ART patients defaulting from care in rural Malawi. Tropical Med Int Health [Internet]. 2010 Apr 29 [cited 2024 Dec 13];15(s1):55-62. https://doi.org/10.1111/j.1365-3156.2010.02504.x Google Scholar


8. Ross J, Ribakare M, Remera E, Murenzi G, Munyaneza A, Hoover DR, Shi Q, Nsanzimana S, Yotebieng M, Nash D, Anastos K, Central Africa IeDEA.High levels of viral load monitoring and viral suppression under Treat All in Rwanda - a cross–sectional study . J Intern AIDS Soc [Internet]. 2020 Jun 14[cited 2024 Dec 13];23(6):e25543. https://doi.org/10.1002/jia2.25543 PubMed | Google Scholar


9. Stern E, Colvin C, Gxabagxaba N, Schutz C, Burton R, Meintjes G. Conceptions of agency and constraint for HIV-positive patients and healthcare workers to support long-term engagement with antiretroviral therapy care in Khayelitsha, South Africa . African Journal of AIDS Research [Internet]. 2017 Apr 2 [cited 2024 Dec 13];16(1):19-2 https://doi.org/10.2989/16085906.2017.1285795 PubMed | Google Scholar


10. Chakravarty J, Kansal S, Tiwary N, Sundar S. Why do Patients in Pre-Anti Retroviral Therapy (ART) Care Default: A Cross-Sectional Study . Indian J Community Med [Internet]. 2016 Jul-Sep[cited 2024 Dec 13];41(3):241-244. https://doi.org/10.4103/0970-0218.183584 PubMed | Google Scholar


11. Paundi F, Musenge E, Nankamba N. Factors Associated with Antiretroviral Therapy Defaulting among Adult Patients Receiving Care at Chikankata Mission Hospital, Chikankata District, Zambia . JBM [Internet]. 2024 May 31 [cited 2024 Dec 13];12(05):340-65. https://doi.org/10.4236/jbm.2024.125026 Google Scholar


12. M Demissie, D Kebede.Defaulting from tuberculosis treatment at the Addis Abeba Tuberculosis Centre and factors associated with it. Ethiop Med J [Internet]. 1994 Apr [cited 2024 Dec 13]; 32 (2):97-106. Abstract only. Google Scholar


13. Gesesew HA, Ward P, Hajito KW, Feyissa GT, Mohammadi L, Mwanri L. Discontinuation from Antiretroviral Therapy: A Continuing Challenge among Adults in HIV Care in Ethiopia: A Systematic Review and Meta-Analysis. Price MA, editor. PLoS ONE [Internet]. 2017 Jan 20 [cited 2024 Dec 13];12(1):e0169651. https://doi.org/10.1371/journal.pone.0169651 PubMed | Google Scholar


14. Kouanfack C, Bede F, Nkfusai CN, Wepngong E, Venyuy MA, Hubert C, Sam DM, Cumber SN. Retention in HIV/AIDS Management Services: is it Really Poor? The Case of Yaounde Central Hospital in Cameroon . Int J MCH AIDS [Internet]. 2020 May 6 [cited 2024 Dec 13];9(2):207-12. https://doi.org/10.21106/ijma.305 PubMed | Google Scholar


15. Barreiro P, Corbatón A, Núñez M, González-Lahoz J, Soriano V.Tolerance of didanosine as enteric-coated capsules versus buffered tablets. AIDS Patient Care and STDs [Internet]. 2004 Aug 25 [cited 2024 Dec 13];18(6):329-31. https://doi.org/10.1089/1087291041444087 Purchase or subscription required to view full text. Google Scholar


16. Lailulo Y, Kitenge M, Jaffer S, Aluko O, Nyasulu PS. Factors associated with antiretroviral treatment failure among people living with HIV on antiretroviral therapy in resource-poor settings: a systematic review and metaanalysis . Syst Rev [Internet]. 2020 Dec 12[cited 2024 Dec 13];9(1):292. https://doi.org/10.1186/s13643-020-01524-1 PubMed | Google Scholar


17. Gesesew HA, Ward P, Woldemichael K, Mwanri L.Prevalence, trend and risk factors for antiretroviral therapy discontinuation among HIV-infected adults in Ethiopia in 2003-2015 . Maga G, editor. PLoS ONE [Internet]. 2017 Jun 16 [cited 2024 Dec 13];12(6):e0179533. https://doi.org/10.1371/journal.pone.0179533 PubMed | Google Scholar


18. Umanah TA, Ncayiyana JR, Nyasulu PS. Predictors of cure among HIV co-infected multidrug-resistant TB patients at Sizwe Tropical Disease Hospital Johannesburg, South Africa. Transactions of the Royal Society of Tropical Medicine and Hygiene [Internet]. 2015 Mar 18 [cited 2024 Dec 13];109(5):340-8. https://doi.org/10.1093/trstmh/trv025 Purchase or subscription required to view full text. Google Scholar


19. Umanah T, Ncayiyana J, Padanilam X, Nyasulu PS. Treatment outcomes in multidrug resistant tuberculosis-human immunodeficiency virus Co-infected patients on anti-retroviral therapy at Sizwe Tropical Disease Hospital Johannesburg, South Africa . BMC Infect Dis [Internet]. 2015 Oct 28 [cited 2024 Dec 13];15(1):478. https://doi.org/10.1186/s12879-015-1214-3 PubMed | Google Scholar


20. Gebremariam MK, Bjune GA, Frich JC.Barriers and facilitators of adherence to TB treatment in patients on concomitant TB and HIV treatment: a qualitative study. BMC Public Health [Internet]. 2010 Oct 28 [cited 2024 Dec 13];10(1):651. https://doi.org/10.1186/1471-2458-10-651 PubMed | Google Scholar


21. Langi GG, Rahadi A, Praptoraharjo I, Ahmad RA. HIV-related stigma and discrimination among health care workers during early program decentralization in rural district Gunungkidul, Indonesia: a cross-sectional study. BMC Health Serv Res [Internet]. 2022 Marc 17 [cited 2024 Dec 13];22(1):356. https://doi.org/10.1186/s12913-022-07751-7 PubMed | Google Scholar


22. Paudel V, Baral KP.Women living with HIV/AIDS (WLHA), battling stigma, discrimination and denial and the role of support groups as a coping strategy: a review of literature. Reprod Health [Internet]. 2015 Jun 2 [cited 2024 Dec 13];12(1):53. https://doi.org/10.1186/s12978-015-0032-9 PubMed | Google Scholar


23. Jennifer L. Weinberg and Carrie L. Kovarik, MD.The WHO Clinical Staging System for HIV/AIDS. AMA Journal of Ethics [Internet]. 2010 Mar 1 [cited 2024 Dec 13];12(3):202-6. https://doi.org/10.1001/virtualmentor.2010.12.3.cprl1-1003 Google Scholar


24. Peltzer K, Mngqundaniso N, Petros G.HIV/AIDS/STI/TB knowledge, beliefs and practices of traditional healers in KwaZulu-Natal, South Africa. AIDS Care [Internet]. 2007 Jan 18 [cited 2024 Dec 13];18(6):608-13. https://doi.org/10.1080/09540120500294206 Purchase or subscription required to view full text. Google Scholar


25. Audet CM, Blevins M, Moon TD, Sidat M, Shepherd BE, Pires P, Vergara A, Vermund SH.HIV/AIDS-related attitudes and practices among traditional healers in Zambézia Province, Mozambique . The Journal of Alternative and Complementary Medicine [Internet]. 2012 Nov 30 [cited 2024 Dec 13];18(12):1133-41. https://doi.org/10.1089/acm.2011.0682 Purchase or subscription required to view full text. PubMed | Google Scholar


26. Hoffman RM, Phiri K, Parent J, Grotts J, Elashoff D, Kawale P, Yeatman S, Currier JS, Schooley A.Factors associated with retention in Option B+ in Malawi: a case control study. Journal of the International AIDS Society [Internet]. 2017 Jan 1[cited 2024 Dec 13];20(1):21464. https://doi.org/10.7448/ias.20.01.21464 PubMed | Google Scholar


27. Boyles TH, Wilkinson LS, Leisegang R, Maartens G. Factors influencing retention in care after starting antiretroviral therapy in a rural south african programme. Wilkinson RJ, editor. PLoS ONE [Internet]. 2011 May 3 [cited 2024 Dec 13];6(5):e19201. https://doi.org/10.1371/journal.pone.0019201 PubMed | Google Scholar


28. Vieira L, Mahumane AM, Napua M, Chale F, Manuel JL, Cowan JG, Sherr K, Chapman RR, Pfeiffer JT.HIV-exposed infant follow-up in Mozambique: formative research findings for the design of a cluster randomized controlled trial to improve testing and ART initiation. BMC Health Serv Res [Internet]. 2020 Mar 18[cited 2024 Dec 13];20(1):226. https://doi.org/10.1186/s12913-020-5051-8 PubMed | Google Scholar


29. Boateng D, Kwapong GD, Agyei-Baffour P.Knowledge, perception about antiretroviral therapy (ART) and prevention of mother-to-child-transmission (PMTCT) and adherence to ART among HIV positive women in the Ashanti Region, Ghana: a cross-sectional study . BMC Women´s Health [Internet]. 2013 Jan 22 [cited 2024 Dec 13];13(1):2. https://doi.org/10.1186/1472-6874-13-2 PubMed | Google Scholar


30. Chalker J, Andualem T, Minzi O, Ntaganira J, Ojoo A, Waako P, Ross-Degnan D.Monitoring adherence and defaulting for antiretroviral therapy in 5 East african countries: an urgent need for standards. Journal of the International Association of Physicians in AIDS Care [Internet]. 2008 Jul 14[cited 2024 Dec 13];7(4):193-9. https://doi.org/10.1177/1545109708320687 Download 1545109708320687.pdf. Google Scholar


31. Park-Wyllie LY, Scalera A, Tseng A, Rourke S.High rate of discontinuations of highly active antiretroviral therapy as a result of antiretroviral intolerance in clinical practice: missed opportunities for adherence support? AIDS [Internet]. 2002 May 3[cited 2024 Dec 13];16(7):1084-6. https://doi.org/10.1097/00002030-200205030-00021 Purchase or subscription required to view full text. Google Scholar


32. Kunches LM, Reinhalter NE, Marquis A, Coakley E, Cohen C, Morris AB, Mazzullo JM.Tolerability of enteric-coated didanosine capsules compared with didanosine tablets in adults with HIV infection . JAIDS Journal of Acquired Immune Deficiency Syndromes [Internet]. 2001 Oct 1[cited 2024 Dec 13];28(2):150-3. https://doi.org/10.1097/00126334-200110010-00006 Purchase or subscription required to view full text. Google Scholar