Original research article
Depression and patterns of self-reported adherence to antiretroviral therapy in Rwanda
International Journal of STD & AIDS 2015, Vol. 26(4) 257–261 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414535206 std.sagepub.com
Emily B Wroe1,2, Bethany L Hedt-Gauthier2,3,4, Molly F Franke2,3, Sabin Nsanzimana5, Jean Bosco Turinimana2 and Peter Drobac2,6
Abstract We determined the prevalence of depression in HIV-infected adults on antiretroviral therapy in rural Rwanda and measured the association of depression with non-adherence. In all, 292 patients on antiretroviral therapy for 6 months were included. Adherence was self-reported by four-day recall, two- and seven-day treatment interruptions, and the CASE Index, which is a composite score accounting for difficulty taking medications on time, the average number of days per week a dose is missed, and the most recent missed dose. A total of 84% and 87% of participants reported good adherence by the four-day recall and CASE Index, respectively; 13% of participants reported two-day treatment interruptions; and 11% were depressed. Depression was significantly associated with two-day treatment interruptions but not with other measures of non-adherence. Self-reported adherence to antiretroviral therapy in rural Rwanda is high. Adherence assessments that do not consider treatment interruptions may miss important patterns of non-adherence, which may be especially prevalent among depressed individuals. Mental health interventions incorporated into routine HIV care may lead to improvements in mental health and adherence.
Keywords HIV, AIDS, Africa, antiretroviral therapy, screening, viral disease, treatment, adherence, depression Date received: 14 January 2014; accepted: 14 April 2014
Introduction Since 2000, Rwanda has made large strides in healthcare, with the highest immunisation coverage in Africa, declining infant and under-five mortality, and rapidly increasing life expectancy.1–4 The Rwandan government has prioritised improving the accessibility and affordability of health services and the quality of care, increasing government spending on health since the 1994 genocide and decentralising services to the district level.2 Similar progress has been seen in HIV treatment in Rwanda. With an estimated HIV prevalence of 3%,1 approximately 99,000 patients started antiretroviral therapy (ART) between 2005 and 2010, and of these, 84% were retained on ART as of June 2010.5 Every year, there is evidence that patients are initiating treatment earlier, with the proportion of patients presenting with stages 3 and 4 dramatically declining from 64% in 2005 to 24% in 2010.5
Previous studies in sub-Saharan Africa have addressed ART adherence rates but very few have looked at concurrent challenges to adhere to the medications. Adherence rates range from 77% overall 1 Department of Internal Medicine, Brigham & Women’s Hospital, Boston, MA, USA 2 Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda 3 Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA 4 University of Rwanda College of Medicine and Health Sciences, Butare, Rwanda 5 Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda 6 Division of Global Health Equity, Brigham & Women’s Hospital, Boston, MA, USA
Corresponding author: Emily Wroe, Department of Internal Medicine, 75 Francis St, Boston, MA 02115, USA. Email: [email protected]
Downloaded from std.sagepub.com at Karolinska Institutets Universitetsbibliotek on July 27, 2015
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adherence with some studies greater than 90%.6–8 However, there exist significant social, economic, and structural barriers to accessing HIV treatment, adhering to treatment, and remaining in care,9,10 and more research is needed to understand risk factors for poor adherence in order to better support patients over the course of lifelong therapy.8 Multiple factors must be considered, including mental health, social capital, and variables related to poverty.11,12 HIV-positive individuals have high rates of depression,13–15 and depressive symptoms have been shown to predict HIV disease progression and mortality in the United States. 16,17 There is evidence that depression is a risk factor for non-adherence to ART in developing contexts,10,15,18 and management of depressive symptoms is a priority for adherence.19 One multi-centre study conducted in the US found that intermittent use of ART, defined as stopping and starting again at least 1 time, explained the observed association between depression and higher mean viral load.17 In this paper, we summarise results from a crosssectional study of patients on ART in the rural Burera District of Rwanda, where health services are provided through the Ministry of Health in partnership with Partners In Health. These data were collected prior to the initiation of an integrated model using community health workers through which patients on HIV treatment receive increased social, economic, and psychological support. The objectives of this study were to (1) estimate the levels of adherence in HIV-infected patients on ART; (2) report the prevalence of depression, and (3) examine the association between depression and ART adherence.
Methods Study setting The study was conducted in three health centres in Burera district, a mountainous rural region in northern Rwanda where the majority of the population relies on subsistence agriculture. Prior to 2008, this district of approximately 350,000 people did not have a district hospital and had one practicing physician, and there were no non-governmental implementation partners supporting the Ministry of Health (MOH) in ART delivery in the district. In 2008, the Rwandan Ministry of Health partnered with Partners In Health and the Clinton Health Access Initiative to strengthen healthcare services in Burera. At that time, approximately 800 patients in the district were on ART according to national guidelines. A key part of the healthcare scale-up was to expand quality HIV treatment services to all health centres with additional services for patients on ART, including nutritional
support, community healthcare workers, and minimisation of out-of-pocket expenses such as user fees and transportation.
Study design and enrollment This is a cross-sectional study that recruited participants from June to September 2008 at the three rural health centres. Individuals visiting the clinic for routine visits and who had been on ART for 6 months or more were eligible for inclusion in the study. Exclusion criteria were age less than 18 years and receipt of ART for less than 6 months. On randomly chosen clinic days, study staff explained the study to all eligible HIVinfected patients waiting for their clinic appointment and invited them to participate. Two hundred ninetytwo patients who provided informed consent were enrolled in the study. At the study visit a trained study nurse administered a questionnaire to assess self-reported adherence and depression.
Outcome assessment and definitions Adherence was measured using multiple self-report methods including four-day recall, two- and seven-day treatment interruptions, and the CASE Index. Selfreported adherence measures have been shown to correlate with viral load results,20,21 and in rural Uganda, treatment interruptions greater than 48 hours have been shown to predict drug–resistance.6 The measures of adherence were designed to capture different aspects of adherence. For example, the four-day recall was used to assess recent adherence, where non-adherence was defined as missing one or more doses in the four days prior to interview. Two-day and seven-day treatment interruptions assess non-adherence on sequential days, which can have important implications for persistent viraemia and viral resistance.6,17 Treatment interruptions suggest intermittent difficulties in adherence caused by missed clinic visits or stock outs, for example. Finally, the three-item CASE Index is a composite score that asks individuals to report three items: (1) the frequency of difficulty taking HIV medications on time, (2) the average number of days per week at least one dose of HIV medications was missed, and (3) how long ago s/he missed a dose of HIV medications.22 Composite scores from the CASE Index range from 3 to 16, with scores >10 indicating good adherence; however, pilot data suggested that participants had difficulty distinguishing between two response categories: missing a dose an average of ‘‘zero times per week’’ and ‘‘less than once a week.’’ We therefore combined these response categories for a total maximum score of 15 and used a CASE index score of 9 or less indicating suboptimal adherence.22
Downloaded from std.sagepub.com at Karolinska Institutets Universitetsbibliotek on July 27, 2015
Wroe et al.
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Exposure assessment and definitions Depression was measured using the Hopkins Symptoms Checklist-15 (HSCL-15), a commonly used tool in primary care settings that has been shown to correlate with other measures of depression.23,24 Participants classify their degree of each of 15 symptoms such as low energy, poor appetite, sleep disturbances, and suicidal thoughts during the past week, scoring each response as 1–4 with higher numbers correlating with more severe depressive symptoms. The scale has been shown to have good reliability (Cronbach’s alpha 0.87) in an HIV-infected population in Rwanda.25 Individuals with an average score of 1.75 or higher across the depressive symptoms are classified as depressed.
Statistical analysis We report the following descriptive statistics: proportion of participants who were adherent (by each selfreport method) and proportion depressed. To examine the association between depression with each selfreported measure of adherence, we used Fisher’s exact test. Multivariable analysis was performed using logistic regression and adjusting for age, gender, and baseline CD4 count. Significance was determined by a two-sided p value of
Depression and patterns of self-reported adherence to antiretroviral therapy in Rwanda
International Journal of STD & AIDS 2015, Vol. 26(4) 257–261 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414535206 std.sagepub.com
Emily B Wroe1,2, Bethany L Hedt-Gauthier2,3,4, Molly F Franke2,3, Sabin Nsanzimana5, Jean Bosco Turinimana2 and Peter Drobac2,6
Abstract We determined the prevalence of depression in HIV-infected adults on antiretroviral therapy in rural Rwanda and measured the association of depression with non-adherence. In all, 292 patients on antiretroviral therapy for 6 months were included. Adherence was self-reported by four-day recall, two- and seven-day treatment interruptions, and the CASE Index, which is a composite score accounting for difficulty taking medications on time, the average number of days per week a dose is missed, and the most recent missed dose. A total of 84% and 87% of participants reported good adherence by the four-day recall and CASE Index, respectively; 13% of participants reported two-day treatment interruptions; and 11% were depressed. Depression was significantly associated with two-day treatment interruptions but not with other measures of non-adherence. Self-reported adherence to antiretroviral therapy in rural Rwanda is high. Adherence assessments that do not consider treatment interruptions may miss important patterns of non-adherence, which may be especially prevalent among depressed individuals. Mental health interventions incorporated into routine HIV care may lead to improvements in mental health and adherence.
Keywords HIV, AIDS, Africa, antiretroviral therapy, screening, viral disease, treatment, adherence, depression Date received: 14 January 2014; accepted: 14 April 2014
Introduction Since 2000, Rwanda has made large strides in healthcare, with the highest immunisation coverage in Africa, declining infant and under-five mortality, and rapidly increasing life expectancy.1–4 The Rwandan government has prioritised improving the accessibility and affordability of health services and the quality of care, increasing government spending on health since the 1994 genocide and decentralising services to the district level.2 Similar progress has been seen in HIV treatment in Rwanda. With an estimated HIV prevalence of 3%,1 approximately 99,000 patients started antiretroviral therapy (ART) between 2005 and 2010, and of these, 84% were retained on ART as of June 2010.5 Every year, there is evidence that patients are initiating treatment earlier, with the proportion of patients presenting with stages 3 and 4 dramatically declining from 64% in 2005 to 24% in 2010.5
Previous studies in sub-Saharan Africa have addressed ART adherence rates but very few have looked at concurrent challenges to adhere to the medications. Adherence rates range from 77% overall 1 Department of Internal Medicine, Brigham & Women’s Hospital, Boston, MA, USA 2 Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda 3 Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA 4 University of Rwanda College of Medicine and Health Sciences, Butare, Rwanda 5 Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda 6 Division of Global Health Equity, Brigham & Women’s Hospital, Boston, MA, USA
Corresponding author: Emily Wroe, Department of Internal Medicine, 75 Francis St, Boston, MA 02115, USA. Email: [email protected]
Downloaded from std.sagepub.com at Karolinska Institutets Universitetsbibliotek on July 27, 2015
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International Journal of STD & AIDS 26(4)
adherence with some studies greater than 90%.6–8 However, there exist significant social, economic, and structural barriers to accessing HIV treatment, adhering to treatment, and remaining in care,9,10 and more research is needed to understand risk factors for poor adherence in order to better support patients over the course of lifelong therapy.8 Multiple factors must be considered, including mental health, social capital, and variables related to poverty.11,12 HIV-positive individuals have high rates of depression,13–15 and depressive symptoms have been shown to predict HIV disease progression and mortality in the United States. 16,17 There is evidence that depression is a risk factor for non-adherence to ART in developing contexts,10,15,18 and management of depressive symptoms is a priority for adherence.19 One multi-centre study conducted in the US found that intermittent use of ART, defined as stopping and starting again at least 1 time, explained the observed association between depression and higher mean viral load.17 In this paper, we summarise results from a crosssectional study of patients on ART in the rural Burera District of Rwanda, where health services are provided through the Ministry of Health in partnership with Partners In Health. These data were collected prior to the initiation of an integrated model using community health workers through which patients on HIV treatment receive increased social, economic, and psychological support. The objectives of this study were to (1) estimate the levels of adherence in HIV-infected patients on ART; (2) report the prevalence of depression, and (3) examine the association between depression and ART adherence.
Methods Study setting The study was conducted in three health centres in Burera district, a mountainous rural region in northern Rwanda where the majority of the population relies on subsistence agriculture. Prior to 2008, this district of approximately 350,000 people did not have a district hospital and had one practicing physician, and there were no non-governmental implementation partners supporting the Ministry of Health (MOH) in ART delivery in the district. In 2008, the Rwandan Ministry of Health partnered with Partners In Health and the Clinton Health Access Initiative to strengthen healthcare services in Burera. At that time, approximately 800 patients in the district were on ART according to national guidelines. A key part of the healthcare scale-up was to expand quality HIV treatment services to all health centres with additional services for patients on ART, including nutritional
support, community healthcare workers, and minimisation of out-of-pocket expenses such as user fees and transportation.
Study design and enrollment This is a cross-sectional study that recruited participants from June to September 2008 at the three rural health centres. Individuals visiting the clinic for routine visits and who had been on ART for 6 months or more were eligible for inclusion in the study. Exclusion criteria were age less than 18 years and receipt of ART for less than 6 months. On randomly chosen clinic days, study staff explained the study to all eligible HIVinfected patients waiting for their clinic appointment and invited them to participate. Two hundred ninetytwo patients who provided informed consent were enrolled in the study. At the study visit a trained study nurse administered a questionnaire to assess self-reported adherence and depression.
Outcome assessment and definitions Adherence was measured using multiple self-report methods including four-day recall, two- and seven-day treatment interruptions, and the CASE Index. Selfreported adherence measures have been shown to correlate with viral load results,20,21 and in rural Uganda, treatment interruptions greater than 48 hours have been shown to predict drug–resistance.6 The measures of adherence were designed to capture different aspects of adherence. For example, the four-day recall was used to assess recent adherence, where non-adherence was defined as missing one or more doses in the four days prior to interview. Two-day and seven-day treatment interruptions assess non-adherence on sequential days, which can have important implications for persistent viraemia and viral resistance.6,17 Treatment interruptions suggest intermittent difficulties in adherence caused by missed clinic visits or stock outs, for example. Finally, the three-item CASE Index is a composite score that asks individuals to report three items: (1) the frequency of difficulty taking HIV medications on time, (2) the average number of days per week at least one dose of HIV medications was missed, and (3) how long ago s/he missed a dose of HIV medications.22 Composite scores from the CASE Index range from 3 to 16, with scores >10 indicating good adherence; however, pilot data suggested that participants had difficulty distinguishing between two response categories: missing a dose an average of ‘‘zero times per week’’ and ‘‘less than once a week.’’ We therefore combined these response categories for a total maximum score of 15 and used a CASE index score of 9 or less indicating suboptimal adherence.22
Downloaded from std.sagepub.com at Karolinska Institutets Universitetsbibliotek on July 27, 2015
Wroe et al.
259
Exposure assessment and definitions Depression was measured using the Hopkins Symptoms Checklist-15 (HSCL-15), a commonly used tool in primary care settings that has been shown to correlate with other measures of depression.23,24 Participants classify their degree of each of 15 symptoms such as low energy, poor appetite, sleep disturbances, and suicidal thoughts during the past week, scoring each response as 1–4 with higher numbers correlating with more severe depressive symptoms. The scale has been shown to have good reliability (Cronbach’s alpha 0.87) in an HIV-infected population in Rwanda.25 Individuals with an average score of 1.75 or higher across the depressive symptoms are classified as depressed.
Statistical analysis We report the following descriptive statistics: proportion of participants who were adherent (by each selfreport method) and proportion depressed. To examine the association between depression with each selfreported measure of adherence, we used Fisher’s exact test. Multivariable analysis was performed using logistic regression and adjusting for age, gender, and baseline CD4 count. Significance was determined by a two-sided p value of
