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EURASIAN EXPERIMENT JOURNAL OF MEDICINE AND MEDICAL SCIENCES
(EEJMMS) ISSN: 2992-4103
©EEJMMS Publications Volume 4 Issue 1 2023
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44
Adolescents and Adherence to Antiretroviral Treatment

Emmanuel Ifeanyi Obeagu1, Getrude Uzoma Obeagu2, Adekemi Linda Adejare3

*

and Okechukwu Paul-Chima Ugwu4

1
Department of Medical Laboratory Science, Kampala International University,
Uganda.
2
School of Nursing Science, Kampala International University, Uganda.
3
Intensive Care Unit, Inspira Medical Center, USA.
4
Department of Publication and Extension, Kampala International University,
Uganda.
Email:emmanuelobeagu@yahoo.com,
Orcid:0000-0002-4538-0161

ABSTRACT
Some factors that are related to adherence to ARV treatment among adolescents are gender, age, marital status, Education,
place of residence, family size and religion. Drug related factors that are related to adherence to ARV treatment among
adolescents include having all the drugs they are supposed to take, challenges faced with the drugs, Frequency of taking ARV
pills in a day, challenges faced when taking ARVs and accessibility to ARV drugs. Health related factors that are related to
adherence to ARV treatment among adolescents are getting routine education and counseling about adherence to ARVs, source
of information, had nearby health care facility to pick ARV drugs, distance between health facility and respondents’ home,
availability of ARV on appointment day, availability of health care workers for ARV services.
Keywords: ART, adolescents, adherence, HIV, AIDS, ARV

INTRODUCTION
Adolescence usually refers to the period between the ages of 13 and 19 and represents the transition from childhood to
adulthood. However, the physical and psychological changes that occur during puberty can begin as early as the teenage years
or between 9 and 12 years of age [1]. On the other hand, the World Health Organization defines adolescence as the age from
her 10 years to her 24 years [2]. In this study, adolescents were considered to be between the ages of 10 and 2. Treatment
adherence is one of the strongest predictors of virologic failure, development of drug resistance, disease progression, and
mortality [3]. Low adherence to combination antiretroviral therapy (CART) is common in both developing and developed
countries [4-8]. It is found in approximately 20% of HIV-infected patients in Africa and approximately 14% in the United States
[9]. By the end of 2014, approximately 37 million people were living with the human immunodeficiency virus (HIV)
worldwide, mostly from low- and middle-income countries. Fifteen million people living with HIV are receiving
antiretroviral (ARV) therapy [10-13], and the number of people with ART has doubled since 2010.Estimates of ART
adherence among adolescents living with HIV (ALHIV) in low- and middle-income countries (LMICs) vary widely [14-18].
Adherence among young people worldwide ranged from 16% to 99% [19]. Since 2014, a meta-analysis of adolescents and young
adults (ages 12–24) from 53 countries has shown an 84% adherence rate based on self-reported or viral load measurements in
both Africa and Asia. [20].

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provided the original work is properly cited.
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Level of adherence to ARVS among adolescents
ART adherence thresholds have historically been set at 95% based on older ART regimens for prescribed doses [21]. In studies
conducted in California and the United States, results showed that medication adherence was between 80% and 90%, which is
sufficient to suppress viral replication [22]. A study of antiretroviral therapy self-adherence and its correlation in Hunan, China,
showed that historically the ART adherence threshold has been set at 95% of the prescribed dose based on older ART regimens.
[23]. However, a study conducted in California, USA, found that 80–90% adherence to the current regimen was sufficient to
suppress viral replication [22]. However, treatment adherence in China is based on the WHO recommendation of ingesting at Page |
least 90% of the prescribed dose, and actual treatment adherence in China may be below the recommended dose, which is the
key to combating viral infections. It should be noted that this causes problems in HIV and AIDS [21]. A cross-sectional study
45
of factors associated with self-reported adherence to antiretroviral therapy in adolescents conducted in Zimbabwe found that
among 262 infected adolescents aged 10 to 19 years who received ARV therapy, adherence was suboptimal. Only 101 individuals
were found to have been infected (39%) reported excellent adherence [24]. This may be due to parental absence from each
clinical meeting, discomfort with asking questions of health care providers, and failure to participate in group sessions led by
professional facilitators. This means that adolescents were not adequately informed about adherence to ART treatment.
Individual factors associated with adherence to ARVs/ART among adolescents
Level of education
Hansana et al. [25] conducted a cross-sectional survey on antiretroviral therapy (ART) adherence among HIV-infected
persons at Setthathirath Hospital in Vientiane, the capital, and Savannakhet Provincial Hospital in Lao People's Democratic
Republic. reported to be low. Relates to adherence to artistic therapy. The results showed that women with an education level
between first grade and her sixth grade were less likely to report adherence than women with higher education levels. This
was because the college-educated adolescent could afford transportation to a drug collection center and was well-informed
about the importance of maintaining her ART treatment on a regular basis. It was because of good access. Respondents were
busy with work and could not replenish their medicines regularly. Similar results were reported in a study conducted in
Vietnam, where university graduates had higher adherence and adherence to ART than those with little or no formal
education [26]. On the contrary, a study carried out in Bangalore India found out that education had no effect on adherence
to ART treatment [27]. This was due to the fact that respondents were generally educated and thus were aware about the
problems of sub-optimal treatment.
Gender
In a cross-sectional study carried out in the Congo Brazzaville, where adherence was higher among females than males [28].
This was attributed to females having more time to attend to health care services which were not the case with males who
had to work. These differences were associated to work schedules and sample selection methods in the two studies.
Age
In an observational longitudinal study carried out in Mumbwa district located 150 km west of Lusaka the capital city of
Zambia, about adherence to ART during the early months of treatment in rural Zambia found out that, respondents who
were older were more likely to adhere to ART as compared to younger respondents [29]. Adolescents above 20 years were
more adherent than younger adolescents because they were old enough to know how to manage their life and had children
whom they wanted to care about so that they also grow. This is why they wanted to be in good health. However, these
results differed from those revealed in a cross sectional and pilot cross sectional studies carried out in Congo Brazzaville
and Gaborone, Botswana respectively where younger age of adolescence was associated with adherence to ART treatment
[28, 30]. This contrast was due to the fact that in previous studies, younger adolescents were directly under the supervision
of their caretakers at home and school while in the present study; it was the adolescents‟ initiative to take the drugs.
Religious beliefs
In a study carried out in different Sub-Saharan countries on the impact of religion in adherence to ARVs/ART treatment
revealed that religious beliefs were found to highly hinder adherence to ART among adolescents living with HIV [31]. In a
study carried out in the Democratic Republic of Congo, found out that respondents who had a belief that ART has God’s
blessings were more likely to adhere to ART treatment while adolescents who had a belief that accepting God and enough
were less likely to adhere to ART treatment. Similar findings were reported in another qualitative study carried out in the
Congo where believers who had a mind-set that God makes everything possible were less likely to adhere to ART treatment.
Marital status
Similar results were reported in a study carried out in Nigeria who found out that forgetfulness to take or collect pills from
the ART clinic was highly associated to lack of support to be remaindered or encouraged to adhere to ART [32]. This was
more prevalent among respondents who were singles or had lost partners due to AIDS.
In a study carried out in urban and rural settings in Uganda were adherence to ART treatment among adolescents was higher
among married couples [33].

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(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
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Place of residence
In a Malawian qualitative study that explored the factors associated with ART adherence and retention in care under
option B+ strategy, found out that, place of residence where adolescents resided highly influenced the level of adherence
to AVR treatment [34]. Adolescents who were settled in place where more likely to adhere to ART treatment as
compared to adolescents who never stayed in one place. This was because ever moving adolescents could not easily access
drugs where they had gone due to last of transfer letters and treatment notes for the new health care providers to start
from. In a study carried out in Uganda, adherence was worse among the rural compared to urban living adolescents. This Page |
was contrary to findings in a cohort study from 2006 to 2011 which was conducted among 1000 children resident in urban
and rural settings of Uganda to compare the response to ART among urban versus rural children and the factors
46
associated with this response. Adherence of ≥95 % was observed in 88.2 % of urban versus 91.3 % of rural children by
self-report, and in 78.8 % of urban versus 88.8 % of rural children by pill counts. This study also reported that rural
children had more favorable clinical outcomes and were more likely to adhere optimally to ART than urban children
(Musiime et al., 2012). However, our study consisted of adolescents who are a special group that needs a lot of psychosocial
support. The urban located facilities in our study had more adolescent friendly services, peer support groups and more
innovations to support ALHIV than in the rural facilities which could explain the better adherence. Studies show that
adolescents are attracted to such adolescent friendly services [35].
Relationship with the people they stay with at home
Nabukeera-Barungi, et al. [36] in a study on adherence to antiretroviral therapy and retention in care for adolescents
living with HIV from 10 districts in Uganda, revealed that, adolescents who never stayed with their biological parents
were less likely to adhere to ART treatment as compared to adolescents who stayed with their parents. This was because the
former was exposed to mistreatment and abuse. Findings showed that the most annoying incidents were being insensitive
that some family members publicly disclosed the HIV status of the adolescents living with HIV before their peers which
demoralized them. This discouraged them to take their medication as they were supposed to do it thus had poor drug
adherence.
Social support
Reisner et al. [37] in a study carried out in the United States of America revealed that, lack of social support from people
adolescents lived with contributed to non-adherence to ARV treatment among adolescents. Inadequacy of social support was
reflected in failure of family members to always remind the patient to take his or her drugs in time, discrimination by
family members and friends which eventually led to stigma among patients. It was due to this laxity that adolescents could
not even go to the clinics to collect their drugs thus non adherence. A study carried out in Thailand on antiretroviral therapy
adherence among patients living with HIV/AIDS revealed that having a higher income, financial aid or support with travel
costs generally improves adherence [38]. Though Thailand has a high National Gross Domestic Product, most of the people
have low incomes, which make access to health care services difficult. Findings showed that, many adolescents in Thailand
who fail to adhere to ARV treatment come from low-income families that, cannot afford accessing treatment where
the major challenges are travel costs and lack of enough disposable income to feed well so that they take the treatment
with less complications. Similar findings were reported in a study carried out in South Africa, showed that, majority of the
respondents that participated in the study lacked family support [39]. Findings showed that, such respondents had
psychological torture due to resentment from their family members which discouraged them to take the drugs as prescribed
due to the stigma they faced.
Forgetfulness
A hospital-based study carried out in India on adherence to ART among adolescents found out that forgetting to take the
pills was one of the major factors for missing pills thus poor adherence [40]. This was more prevalent among respondents
who were not staying with a companion to remind them of taking their drugs or assist them to collect them from the ART
clinic on appointment days in case they were busy or weak. Similar results were reported in a study carried out in Nigeria
who found out that forgetfulness to take or collect pills from the ART clinic was highly associated to lack of support to be
remaindered or encouraged to adhere to ART [32]. This was more prevalent among respondents who were singles or had
lost partners due to AIDS.
Side effects
A study on the skin disease among HIV infected adolescents in Zimbabwe, it was found out that skin disfiguration was
associated with increased adherence to ART therapy among adolescents. Given that the youth feared to be discriminated
and excommunicated by their peers they thought that taking their medication will help them [41].
Taking of illicit drugs
In a study carried out in the United States of America on the review of HIV antiretroviral adherence and intervention
studies among HIV-infected youth, it was found out that, adolescents who used illicit drugs were less likely to adhere to ART
treatment as compared to adolescents who never used illicit drugs. Findings showed that, adolescents who took less alcohol
in the past week before the study and less drugs in the previous three months were more likely to adhere to ART treatment
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as compared to their counterparts who had used more of them. Higher adherence was found among adolescents who never
took any illicit drugs as compared to those who used them [37].
Culture
A study on an exploration of factors influencing adherence to highly active antiretroviral therapy (HAART) among people
living with HIV/AIDS in Northern Thailand reported that, in families where family culture acknowledged taking of modern
medication on different complication, there was good adherence to antiretroviral therapy. This was attributed to fear of being
excluded from their families and society which was a highly feared life experience since people worked and shared as Page |
families. A study on the barrier to ARV adherence among HIV/AIDS positive persons taking ARV therapy in two Tanzania
Regions between 8-12 months revealed high belief of being bewitched or of having a spell case on them or AIDS devil/spirit 47
being witchcraft lead to low drug adherence [42]. Most adolescents who stayed with elders who had poor health care
seeking behavior were most likely to have much trust in traditional medicine and subsequent great belief in cultural
norms and were less likely to adhere to modern medicine where a case in point was poor adherence to ART treatment.
Caregiver beliefs
A qualitative study carried out in Sub Saharan Africa on disclosure to adolescents about their HIV status, revealed that,
adherence to AVR treatment was associated to adolescents age [43]. Respondents who were between 15 and 18 years were
more likely to adhere to ART treatment as compared to adolescents who were between 19 and 24 years. The explanation
was that younger adolescents were more likely to remind their caretakers their medication as young children are more
obedient to their elders which was not the cases with older adolescents who were disobedient to their caretakers and felt
stigmatized by their age mates who saw them taking the drugs. Similar results were reported in a study carried out in different
Sub-Saharan countries where adolescents who held beliefs that HIV can be treated with other medications apart from
ARVs were less likely to adhere to ART treatment [31].
Diseases stage
A pilot cross-sectional study on the risk factors for suboptimal antiretroviral therapy adherence in HIV-infected
adolescents in Gaborone, Botswana showed that the diseases stage was associated adherence to ART treatment to the disease
stage [44]. Findings revealed that adolescents in WHO stage III/IV were more likely to adhere to treatment compared to
their counterparts who were in lower stages. This was associated to the fact that relatively healthy adolescents were reluctant
about taking their medications because most of them perceived it an inconvenience since they were not feeling bad.
Number of family members
A study cross sectional study on the factors associated with adherence to antiretroviral therapy among HIV infected children
in Kabale district, Uganda adherence was higher among families with smaller number of members as compared to those with
many members [45]. The difference was that, in a study carried out in Kabale larger families had poor adherence due to need
of labour to work in agriculture to produce food for the family while in the present study larger families prioritized resources
to feeding.
Drug relation factors associated with adherence to ARV treatment among adolescents
Availability of the drugs
A study carried out in middle- and low-income countries about antiretroviral therapy adherence and retention showed that
availability of drugs is influenced by structural factors that may not be directly related to patient or medication [46].
Biadggilign et al. [47] in a study carried out in Ethiopia found out that limited availability and accessibility to antiretroviral
medications and health care facilities for diagnosis was responsible for poor adherence to ART treatment.
Duration on drugs
A cross sectional study carried out in Lao People’s Democratic Republic about adherence to ART among people Living
with HIV found out that patients who had been on ART for more than two years were non-adherent as compared to those who
had just been initiated on ART [25]. This was associated to complacency patients developed overtime that they no longer
followed the strict regimen. In a study carried out in Northern Vietnam about the barriers to and strategies for adherence to
antiretroviral therapy among HIV patients found out that being on ART for a period between two and half years to five
years was significantly associated with non-adherence to ART [26].
CONCLUSION
Individual factors that are associated with adherence to ARV treatment among adolescents are gender, age, marital status,
Education, place of residence, family size and religion. Drug related factors that are associated with adherence to ARV
treatment among adolescents include having all the drugs they are supposed to take, challenges faced with the drugs,
Frequency of taking ARV pills in a day, challenges faced when taking ARVs and accessibility to ARV drugs. Health related
factors that are associated with adherence to ARV treatment among adolescents are getting routine education and counseling
about adherence to ARVs, source of information, had nearby health care facility to pick ARV drugs, distance between health
facility and respondents’ home, availability of ARV on appointment day, availability of health care workers for ARV services,
frequency of ARVs refilling at the clinic and waiting time on the appointment day to pick the drugs.

© Obeagu et al., 2023

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(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
https://www.eejournals.org Open Access
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provided the original work is properly cited.
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