Short Communication

Antiretroviral Therapy in Zambia: Do Partners on ART Enhance Adherence?

Journal of the International Association of Providers of AIDS Care 2014, Vol. 13(6) 497–500 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2325957414553843 jiapac.sagepub.com

Deborah Jones, PhD1, Ryan Cook, BA1, Andrew Spence, BS1, Stephen M. Weiss, PhD, MPH1, and Ndashi Chitalu, MD, MPH2

Abstract Background: Adherence to antiretroviral therapy (ART) is essential to optimize HIV treatment outcomes. Among individuals on ART, targeted peer support has been found to support adherence. This study of Zambian heterosexual couples living with HIV examined whether partners would exert a positive influence on each other’s adherence, and compared adherence between couples in which either one or both members were on ART. Methods: Couples (n ¼ 446 participants), in which either or both member were on ART were assessed at baseline, 6 and 12 months. Results: Most participants (64%, n ¼ 263) were on ART; overall, uptake of ART increased to 74% at 12 months. At baseline, 76% reported near perfect adherence; at 6 and 12 months, 66% and 70% were adherent, respectively. A regression analysis indicated that the decline in adherence did not differ between those couples in which one or both partners were on ART [F (2, 624) ¼ 0.37, p ¼ .692]. Pairwise comparison indicated that adherence primarily decreased between baseline and 6 months (t ¼ 2.72, p = .007), and was stable 6 to 12 months. Conclusions: This study of couples in Zambia found adherence was not enhanced by having a partner on ART, and that adherence declined over time. Partners on ART may not necessarily provide support for adherence to each other. Partners may represent an untapped resource for optimizing adherence; results highlight the need for provider guidance and structured adherence interventions targeting partner adherence support. Keywords HIV, Zambia, adherence, ART, couples

Background Optimal health outcomes among patients living with HIV are dependent on adherence to antiretroviral (ARV) medication regimens and ongoing clinical care. Literature addressing chronic illness suggests that patients may be nonadherent due to multiple factors and that peer, partner, spousal, or caregiver support may play an important role in encouraging patients to achieve medication regimen goals.1–5 In fact, support may be most important early in illness, when dropout is more likely to occur.1–2 However, perception by patients of familial disinterest in their illness may also have a deleterious effect on adherence, 6 and familial adherence partners may be perceived as controlling or undesirable. 7 Globally, many behavioral interventions designed to support persons living with HIV have utilized peers or ‘‘clinic buddies.’’8 However, although targeting both members of couples has been used as a strategy to prevent sexual transmission and mother to child transmission,9–11 the influence of couple members on adherence has not been examined. Couple members in sub-Saharan Africa are often both HIV-infected, on ARV treatment, and living in the same home environment where ARV medication behaviors take place and may share a commitment to the health and integrity of their family. HIV testing of couples in Africa has been an

effective prevention strategy for more than 20 years.9,12 Yet, couple members are not generally trained to provide the social or informational support to each other typically found in peer interventions. Peer support to enhance adherence has been successful in increasing self-reported adherence in sub-Saharan African treatment programs (eg, Zambia Clinic Buddy Visit Support1, Mozambique Directly Observed Therapy [DOT]13). However, the impact of peer interventions on self-reported adherence may be overestimated and may not be reflected in biomarkers of disease suppression that indicate adherence, such as HIV-1 RNA viral load.14,15 This study of Zambian heterosexual HIV seroconcordant and serodiscordant couples in urban Lusaka examined the influence of partners on each other’s adherence and compared

1

University of Miami Miller School of Medicine, Department of Psychiatry & Behavioral, Miami, FL, USA 2 University of Zambia School of Medicine, Department of Paediatrics, Lusaka, Zambia Corresponding Author: Deborah Jones, Department of Psychiatry & Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave, Miami, FL 33141, USA. Email: [email protected]

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Table 1. Longitudinal Adherence among 263 Zambian HIV-Positive Individuals Taking ART. Parameter

B (SE)

Time 6 months versus baseline (ref) 12 months versus baseline (ref) Medication concordant versus discordant (ref) Alcohol use versus no alcohol use (ref) Time since HIV diagnosis (1-year difference) Years of education (1-year difference)

t, P

.530 (.195) .201 (.210) .216 (.205) .520 (.248) .004 (.003) .091 (.034)

2.72, 0.96, 1.06, 2.10, 1.42, 2.66,

.007 .337 .291 .036 .157 .008

OR 0.589 0.818 1.241 0.594 1.004 1.095

95% CI (OR) (0.402, (0.542, (0.831, (0.365, (0.998, (1.024,

0.863) 1.234) 1.854) 0.967) 1.009) 1.171)

Abbreviations: ART, antiretroviral therapy; CI, confidence interval; OR, odds ratio; ref, reference; SE, standard error.

adherence between couples in which either one or both members were on antiretroviral therapy (ART). It was hypothesized that couples in which both members were on ART would report greater adherence due to mutual support.

Methods This study is drawn from a larger research study, the Partnership II research project, a longitudinal implementation study for couples living with HIV attending community health clinics (CHCs).16 Participants (n ¼ 446) were HIV-positive seroconcordant heterosexual couples (n ¼ 223) recruited from 6 CHCs in urban Lusaka, Zambia, willing to attend study visits over a 12-month period. All participants were 18 years of age or older, HIV-positive, sexually active within the last 30 days, and in a relationship with their enrolled partner for at least 6 months. Participants’ HIV serostatus was confirmed prior to enrollment from testing records, but mutual serostatus disclosure was not a requirement for participation. Approximately 30% of couples screened for enrollment were not eligible due to lack of sexual activity in the previous months or inability to enroll with a primary sexual partner (no partner, not in a 6-month relationship, and recent breakup). All partners had disclosed their HIV status to each other at the time of enrollment, and participants were not enrolled within 2 weeks of HIV diagnosis. All consents and assessments were conducted in English, Nyanja, or Bemba, the primary local languages in Lusaka, and Zambian study staff members consenting participants were fluent in all 3 languages. Following the provision of informed consent, both the couple members completed a baseline assessment using an Audio Computer Assisted Self-Interview in order to minimize social desirability bias and data collection errors.17 Participants were compensated for their time and travel expenses (K50 000 Zambian Kwacha, *US$10). Prior to study onset, ethical review and approval was obtained from the University of Miami Miller School of Medicine Institutional Review Board and the University of Zambia Research Ethics Committee, in accordance with the provisions of the US Department of Health and Human Services and the Zambian government. Participants provided information on demographic, social, and behavioral characteristics. Adherence data were collected using the AIDS Clinical Trials Group adherence instrument.18 All data among partners were collected

individually. A longitudinal multivariable model was used to examine adherence including time (baseline, 6-, and 12month follow-up), couple medication status (time varying; medication concordant versus medication discordant), and the interaction between time and medication status as predictors of interest. Variables were included as covariates in the model if they were significantly related to baseline adherence in bivariate analyses.

Demographics and ART Use Participants (N ¼ 446) were an average of 38 + 8 years old, with 8 + 3 years of education. Most were unemployed (61%), married (97%), and had children (90%). On average, male participants were 6 years older than female participants (t ¼ 8.75, P < .001). The mean number of children was 3 + 2. At baseline, 35 participants were HIV-sero-negative, and thus 35 couples were HIV-serodiscordant. Two hundred sixty-three participants were taking ART at baseline, and 64% of those were HIV positive. On average, these participants had been diagnosed with HIV for 4.5 + 3.5 years. The proportion of participants prescribed ART increased to 70% at 6 months and 74% at 12 months. Similarly, the proportion of couples in which both members used ART (medication concordant) increased from 37% at baseline to 44% at 6 months and 48% at 12-month follow-up.

Adherence and Couple’s ART Status Nonadherence was defined as any missed doses in the past 2 weeks. At baseline, most participants were adherent to their medication (198 of 261 on medication, 76%). The proportion of adherent participants declined to 66% (143 of 217) at 6 months and returned to 70% (136 of 193) at 12-month follow-up. Adherence at baseline was not related to loss to follow up at 6 months (chi-square, w2 ¼ 1.25, P ¼ .264) or 12 months (w2 ¼ 0.877, P ¼ .349). Adherence also did not differ between individuals in HIV-seroconcordant and -serodiscordant couples (w2 ¼ 0.81, P ¼ .369). A longitudinal multivariable model was used to examine adherence over time, testing for differences between medication-concordant and medication-discordant couples and controlling for factors that may impact adherence (ie, alcohol use, time since HIV diagnosis, education level). The results of this

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analysis are presented in Table 1. In summary, the interaction between time and medication status was not significant (F2, 624 ¼ 0.37, P ¼ .692), indicating that the changes in adherence over time were not different between medication-concordant and -discordant couples, and thus it was removed from the model. In contrast, the main effect of time was significant (F2, 626 ¼ 3.82, P ¼ .022), indicating that medication adherence declined over the course of study participation. Pairwise comparisons of time points revealed that participants’ adherence declined from baseline to 6 months (t ¼ 2.72, P ¼ .007). No evidence of a statistically significant change in adherence was found between 6 and 12 months (t ¼ 1.64, P ¼ .102; see Table 1). In order to examine the mutual influence of couple members on each other’s adherence, couples in which both members were taking medication were stratified according to the baseline adherence of 1 member of the couple, and the other member’s adherence was examined over time. Individuals with a nonadherent partner did not change their adherence over time (F2, 69 ¼ 0.24, P ¼ .784); similarly, those with an adherent partner did not change (F2, 279 ¼ 1.19, P ¼ .306). Both subgroups demonstrated a similar pattern of decline in adherence from baseline to 6 months and slight increase between 6 and 12 months.

Discussion This study of Zambian heterosexual HIV seroconcordant and serodiscordant couples examined the influence of partners on each other’s adherence and compared adherence between couples in which either one or both members were on ART. In contrast to the hypothesis, couples in which both members were on ART were no more adherent than those who were ART discordant, and overall, adherence declined among all couples over time. Caregivers, especially spouses, can influence adherence both positively and negatively. Partners may provide information or guidance, tangible support or material support, and social or emotional support to enhance adherence. Unlike previous studies of chronic conditions, having a partner on medication did not enhance adherence, and partner adherence behavior did not appear to positively or negatively influence couple members. As noted in earlier studies,1,8 while peers or ‘‘clinic buddies’’ can complement health care interventions and provide social support, effective peer support may need to comprise targeted strategies that include training and guidance. Although spouses may provide support, unsupportive behavior and lack of spousal knowledge of issues surrounding illness may lower adherence. In fact, patients may even feel their attempts to adhere are sabotaged by family members.6 Higher educational attainment was associated with greater adherence, which may underscore the need for health care providers to offer both patients and partners more information and guidance on the relationship between medication and treatment outcomes.19 Training partners to act as role models,20 rather than ‘‘enforcers,’’ of adherence has been suggested as a method to enhance patient self-efficacy to best manage their

medication. In this context, peer social support would reinforce the patient’s self-efficacy to follow the ART treatment regimen, rather than to push the patient to achieve the necessary adherence behavior.21 Self-efficacy would thus be for the patient to feel confident in his or her ability to initiate and maintain an appropriate level of adherence that will result in optimal health and to perceive optimal adherence to be worth the effort.20 Finally, the mechanisms underlying the positive relationship between adherence and peer support may also be derived from engagement in health care arising from the influence of social comparison, social influence, and practical, tangible social support in the form of material resources.22 As previously found in studies in sub-Saharan Africa, many participants reported high levels of adherence.1,23–25 Unlike studies in which adherence was maintained or increased,23 adherence declined over time. Similar to other studies,1 the decline appeared most precipitous in the first months of study participation. Although no relationship was found between time since HIV diagnosis and adherence, this may have reflected time on medication. As has been noted by Nachega and colleagues,24 maintaining adherence may require patients to shift from treatment adherence to survive to treatment adherence to live. Health care providers may need to guide patients and partners in transitioning from crisis care to maintenance care to strengthen long-term engagement.

Limitations Strengths and limitations of this study should be noted. To our knowledge, this is the first longitudinal study of dyads in Zambia addressing the mutual impact of adherence behaviors. The primary limitations of the study are that all adherence data were self-reported, and time on medication and biological markers for adherence were not collected. However, the time since HIV diagnosis may be related to time on medication and may reduce the impact of this limitation. As reliance on ART becomes widely recognized as an element of the HIV prevention armamentarium,26 adherence among sexual partners becomes increasingly critical. Results suggest health care providers cannot assume spousal support for adherence and should identify and cultivate spousal or caregiver behaviors that may enhance patient adherence. Future interventions should take advantage of partners as potential adherence role models and cultivate partner knowledge and support for optimal health outcomes in patients living with HIV. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding This study was funded by a grant from NICHD/NIH, R01HD058481.

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