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India has a population of more than 1 billion people. Although only about 0.7% of its population is infected with HIV, it has more cases than any other country in the world, with more than 4.5 million HIV-seropositive patients. The epidemic of HIV/AIDS in India is distributed between the urban and rural populations mainly in the southern and western states of the country (APAC-VHS, Community Prevalence of Sexually Transmitted Diseases in Tamil Nadu-A Report, 1998; Solomon, Kumarasamy, Ganesh, & Amalraj, 1998, International Journal of Medical Research, 85; 335-338). India has several different epidemics in various parts of the country. The epidemic in the western and southern states is primarily heterosexual. The northeastern states of India, being in geographical proximity to the Golden Triangle of Asia, initially experienced HIV in the injection drug user population and their sexual partners, but spread to the heterosexual population has been increasing. At present, the northern states, which are the most densely populated, appear to remain largely unaffected by the HIV epidemic. India has mounted a broad intervention program, including the government, and international, nongovernmental, and community-based organizations. The main barriers to effective control are insufficient resources, illiteracy, and stigma. Antiretroviral drugs are manufactured in the country and exported elsewhere, but their affordability (despite a drastic reduction in costs) and the feasibility of monitoring patients on drugs are in question. Starting April 1, 2004, the government of India has announced free provision of ART drugs to all who need it in the six most prevalent states of India.
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PMID:A review of the HIV epidemic in India. 1526 73

Little research exists on acceptability issues related to assessments of adherence to ART in resource-poor settings. To help prepare for two large-scale, multisite ART intervention trials, this qualitative study of individuals in Chennai, India (49 men, 11 women; 33 taking ART, 27 not) and Lilongwe, Malawi (5 men, 5 women, all taking ART) examined potential limitations of different types of adherence assessments: an adherence questionnaire, a pill diary, a pillbox, an electronic pill cap, and a medication punch card. Many participants reported that the various assessments would be acceptable. Potential limitations included issues surrounding literacy, the desire to appease one's medical provider, privacy and stigma, and "cheating." These potential limitations are similar to the limitations of these assessments in Western settings. However, the data highlight the need to consider individual patient level concerns when assessing ART adherence in different cultural settings. Innovative ways of monitoring adherence while maintaining standardization across sites are required in multisite trials.
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PMID:Perceptions about the acceptability of assessments of HIV medication adherence in Lilongwe, Malawi and Chennai, India. 1660 97

Pediatric adherence to daily drug regimens has not been widely assessed in Africa where majority of HIV infected children live. Using in-depth interviews of 42 HIV-infected children taking ART and/or cotrimoxazole prophylaxis, and 42 primary caregivers, at a comprehensive HIV/AIDS clinic in Uganda, we evaluated their adherence experiences for purposes of program improvement. Daily drug regimens provided by the pediatric clinic included cotrimoxazole prophylaxis as well as ART and cotrimoxazole combined. Complete disclosure of HIV status by caregivers to children and strong parental relationships were related to good adherence. Structural factors including poverty and stigma were barriers to adherence even for children who had had complete disclosure and a supportive relationship with a parent. To ensure adherence to life-extending medications, our findings underscore the need for providers to support caregivers to disclose, provide on-going support and maintain open communication with HIV-infected children taking cotrimoxazole prophylaxis and ART.
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PMID:Disclosure of HIV status and adherence to daily drug regimens among HIV-infected children in Uganda. 1679 25

Formative data on the sexual behaviors of HIV-infected individuals in regions disproportionately affected by the epidemic can help generate hypotheses about sexual risk taking in HIV-infected individuals and shape interventions to prevent further transmission. India is home to the highest number of HIV-infected individuals in the world, and very little information is available about the sexual behaviors of HIV-infected Indians. The present qualitative study presents themes from individual in-depth interviews with 30 HIV-infected individuals in South India. The sample included individuals from demographic groups that may experience different risk factors (five individuals each: from men who have sex with men, sex workers, married men, married women, injection drug users, and truck drivers ormen who travel for work). Across the groups, the three most frequently discussed themes involved (a) sexual behavior change (sexual risk reduction after HIV diagnosis, sexual behavior remaining safe after initiation of ART treatment), (b) motivations to reduce risk (motivation to protect one's self against further infection, to protect others from infection), and (c) barriers to reduce risk (complexity and stigma associated with condom negotiation, perception of HIV-infected peers being less concerned about protecting others, condom use as linked to gender and sexual roles, condom use as inconvenient or unappealing). This qualitative data can be used to generate hypotheses about sexual risk taking in HIV-infected individuals in South India, to inform models of risky behaviors of HIV-infected individuals for quantitative studies, and to lay the groundwork for secondary prevention intervention efforts that enhance facilitators and reduce barriers of safer sex articulated by the interviewees.
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PMID:Sexual behaviors of individuals with HIV living in South India: a qualitative study. 1768 46

To respond to the HIV/AIDS epidemic in China, the National Center for AIDS/STD Control and Prevention established the Division of Treatment and Care in late 2001. The pilot for the National Free ART Program began in Henan Province in 2002, and the program fully began in 2003. Treatment efforts initially focused on patients infected through illicit blood and plasma donation in the mid-1990s and subsequently expanded to include HIV-infected injection drug users, commercial sex workers, pregnant women, and children. The National Free ART Database was established in late 2004, and includes data on current patients and those treated before 2004. Over 31 000 adult and pediatric patients have been treated thus far. Challenges for the program include integration of drug treatment services with ART, an under-resourced health care system, co-infections, stigma, discrimination, drug resistance, and procurement of second-line ART. The merging of national treatment and care, epidemiologic, and drug resistance databases will be critical for a better understanding of the epidemic, for earlier identification of patients requiring ART, and for improved patient follow-up. The Free ART Program has made considerable progress in providing the necessary care and treatment for HIV-infected people in China and has strong government support for continued improvement and expansion.
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PMID:The Chinese free antiretroviral treatment program: challenges and responses. 1817 83

We conducted a study to assess the effect of family-based treatment on adherence amongst HIV-infected parents and their HIV-infected children attending the Mother-To-Child-Transmission Plus program in Kampala, Uganda. Adherence was assessed using home-based pill counts and self-report. Mean adherence was over 94%. Depression was associated with incomplete adherence on multivariable analysis. Adherence declined over time. Qualitative interviews revealed lack of transportation money, stigma, clinical response to therapy, drug packaging, and cost of therapy may impact adherence. Our results indicate that providing ART to all eligible HIV-infected members in a household is associated with excellent adherence in both parents and children. Adherence to ART among new parents declines over time, even when patients receive treatment at no cost. Depression should be addressed as a potential barrier to adherence. Further study is necessary to assess the long-term impact of this family treatment model on adherence to ART in resource-limited settings.
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PMID:Longitudinal antiretroviral adherence in HIV+ Ugandan parents and their children initiating HAART in the MTCT-Plus family treatment model: role of depression in declining adherence over time. 1966 22

HIV transmission and occurrence of AIDS in the Middle East and North Africa region (MENA) is increasing, while access to ART in the region lags behind most low to middle-income countries. Like in other parts of the world, there is a growing feminization of the epidemic, and men and women each confront unique barriers to adequate HIV prevention and treatment services, while sharing some common obstacles as well. This paper focuses on important gender dimensions of access to HIV testing, care and treatment in the MENA region, including issues related to stigma, religion and morality, gender power imbalances, work status, and migration. Culturally specific policy and programmatic recommendations for improving HIV prevention and treatment in the MENA region are offered.
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PMID:Gender and care: access to HIV testing, care, and treatment. 1955 77

Medication adherence is a complex behaviour with multiple determinants. Understanding the barriers and facilitators of adherence is invaluable for programme improvement, which assists the foundation of adherence intervention strategies. A qualitative study was conducted in six selected hospitals of Addis Ababa in 2008, to explore barriers and facilitators to antiretroviral medication adherence among HIV-infected paediatric patients. Twelve caregivers of adherent and non-adherent children and 14 key informants in five hospitals were included in the study. The findings revealed that over-dosage (heavy pill burden), fear of stigma and discrimination, cost and access to transportation, lack of understanding of the benefit of taking the medication, economic problems in the household, and lack of nutritional support were the barriers to adherence to HAART. The presence of mobile/wall alarm, the presence of follow-up counselling, improved health of the child, ART clinic setups, and disclosure of HIV serostatus were among the facilitators. This study indicated that paediatric adherence to antiretroviral therapy faces a huge challenge. It suggests the provision of income-generating schemes to caregivers for assisting HIV-infected children. Health care providers should address proper usage of medication reminders.
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PMID:Barriers and facilitators to antiretroviral medication adherence among HIV-infected paediatric patients in Ethiopia: A qualitative study. 2048 54

The purpose of this study was to assess the factors that influence ART adherence arising in rural settings in Zambia. A survey was conducted with face-to-face interviews using a semi-structured questionnaire and written informed consent was obtained at ART sites in Mumbwa District in rural Zambia. The questionnaire included items such as the socio-demographic characteristics of respondents, support for adherence, ways to remember when to take ARVs at scheduled times, and the current status of adherence. Valid responses were obtained from 518 research participants. The mean age of the respondents was 38.3 years and the average treatment period was 12.5 months. More than half of the respondents (51%) were farmers, about half (49%) did not own a watch, and 10% of them used the position of the sun to remember when to take ARVs. Sixteen percent of respondents experienced fear of stigma resulting from taking ARVs at work or home, and 10% felt pressured to share ARVs with someone. Eighty-eight percent of the participants reported that they had never missed ARVs in the past four days. Multivariable logistic regression analysis identified age (38 years old or less, odds ratio (OR) = 2.5, 95% confidence interval (CI): 1.3-4.8, p=0.005), "remembering when to take ARVs based on the position of the sun" (OR = 3.3, 95% CI: 1.3-8.8, p=0.016), and "feeling pressured to share ARVs with someone" (OR = 4.4, 95% CI: 1.6-12.0, p=0.004) as independent factors for low adherence. As ART services expand to rural areas, program implementers should pay more attention to more specific factors arising in rural settings since they may differ from those in urban settings.
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PMID:Social factors affecting ART adherence in rural settings in Zambia. 2140 Mar 14

While the World Health Organization acknowledges the potential of antiretroviral therapy to reduce HIV-related stigma, few studies examine the nature of this linkage. This article discusses the connection between ART and HIV-related stigma, using qualitative analysis of interviews with HIV-positive adults at a rural South African clinic. The data has two main implications for ART's role in stigma reduction: it strengthens the plausibility that ART can reduce stigma through weakening HIV/AIDS's link with disfigurement and death, and shows that ART enables the establishment of spaces for support, which reduce stigma through normalization of the disease.
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PMID:'A virus and nothing else': the effect of ART on HIV-related stigma in rural South Africa. 2208 Mar 86


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