CHRISMED Journal of Health and Research

: 2020  |  Volume : 7  |  Issue : 3  |  Page : 197--201

Assessments of the level of adherence to antiretroviral therapy and the health status of people living with HIV in Calabar, Nigeria

Etefia U Etefia, Solomon A Ben, Paul C Inyang-Etoh 
 Department of Medical Laboratory Science, University of Calabar, Calabar, Nigeria

Correspondence Address:
Etefia U Etefia
Department of Medical Laboratory Science, University of Calabar, Calabar


Background: Medication adherence describes a patient's behavior of accurately following drug regimens; nonadherence describes a patient's inability to accurately follow drug regimens. Several factors such as psychosocial, educational, health-related, and environmental-related factors could contribute in determining the level of adherence to antiretroviral drug. This was a study to assess the level of adherence antiretroviral combination therapy and the health status of people living with HIV in Calabar, Nigeria. Materials and Methods: Questionnaires were administered to 350 HIV persons who attended antiretroviral treatment (ART) clinic to obtain their sociodemographic data, knowledge of ART, service received, and drug history. Stool samples were collected and examined using direct microscopy, formol–ether concentration technique, and modified Ziehl–Neelsen technique for enteric parasites, whereas blood samples were collected for HIV status examination using serial HIV testing algorithm, hemoglobin levels using cyanmethemoglobin method, and counting of CD4 using Partec CyFlow counter. Results: The results showed that 79.43% (278/350) of the participants adhered to antiretroviral drugs, with most of them (47.84%, 133/278) having CD4 counts between 201 and 400 cell/μl. Stigma was the major reason for nonadherence to treatment. Those who adhered to therapy had a lower infection rate and an elevated mean hemoglobin level than those who did not adhere. Conclusion: There was also an elevated hemoglobin level, lower enteric parasite infections, and an improved CD4 count among the adherents than those who did not adhere.

How to cite this article:
Etefia EU, Ben SA, Inyang-Etoh PC. Assessments of the level of adherence to antiretroviral therapy and the health status of people living with HIV in Calabar, Nigeria.CHRISMED J Health Res 2020;7:197-201

How to cite this URL:
Etefia EU, Ben SA, Inyang-Etoh PC. Assessments of the level of adherence to antiretroviral therapy and the health status of people living with HIV in Calabar, Nigeria. CHRISMED J Health Res [serial online] 2020 [cited 2022 Aug 8 ];7:197-201
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Currently, infection with HIV has no cure, but HIV transmission could be controlled and limited by antiretroviral combination therapy, and HIV carriers and those who are potentially at risk of contracting the virus can enjoy healthy, long, and productive lives.[1]

Many literatures have reported that adequate use of combination of the antiretroviral drugs inhibits HIV replication leading to a significant decline in HIV-associated mortality[2] and has improved the health of large number of persons living with HIV. However, the effectiveness of the antiretroviral drugs depends on the level of adherence to the drugs.[3]

Medication adherence is used to describe a patient's behavior of accurately following drugs regimens,[4],[5] whereas nonadherence is used to describe a patient's inability to accurately follow drug regimens. Several factors could contribute in determining the level of adherence to antiretroviral drug, which include patient-related factors (psychosocial and educational), health system-related factors (interaction with physicians and other health workers and access to medications), factors relating to antiretroviral treatment (ART) (pill burden, dosing frequency and adverse effects of medications, duration of medications, and presence of comorbidity), and environmental factors.[6],[7]

Several methods exist for the assessment of drug adherence and its effect in medical setting. It is, however, difficult to determine the method that generates the best estimate of a patient's drug adherence level and its effects because there is no gold standard for the assessment of level of adherence.[8]

The methods used in the evaluation of drug adherence are mostly the assessments of medication refill history and patient-recall assessment because they are easy to perform. Although there are schools of thought that these methods are unskillful with limited accuracy, others have opined that the patient-recall and refill history assessments are accurate enough, especially when they are in a combined state. However, they are generally considered as processes which can lead to exaggeration of medication adherence.[9] Comparatively, method like pill count is laborious and relies upon the assumption that medications missing from the pill bottle were taken. Furthermore, it depends on accurate reporting dates for starting prescriptions but can be more precise when carefully performed.[9]

The aim of this study was to evaluate the level of adherence, the contributory factors to adherence and nonadherence, and the health status of people living with HIV on antiretroviral combination therapy in Calabar, Nigeria.

 Materials and Methods

Study area

The area of study is Calabar, the capital of Cross River State made up of Calabar Municipal and Calabar South Local Government Areas in the south-south region of Nigeria.

Study design

This was a descriptive cross-sectional study involving 350 HIV-positive persons who attended ART clinic in General Hospital, Calabar; Lawrence Henshaw Memorial Hospital, Calabar; Primary Health Centre, Ekpo Abasi, Calabar; and FHI 360, Calabar, through testing of consented participants. Questionnaires were administered to the participants to obtain their sociodemographics.

Inclusion criteria and exclusion criteria

All HIV-positive persons who were on antiretroviral combination therapy were included in the study. Those who were on specific antienteric helminthic drugs and hematinics in the last 2 weeks preceding specimen collection were excluded from the study.

Sociodemographical data collection

Questionnaires were administered to the participants to obtain their sociodemographic information such as age, sex, residence, marital status, level of education, occupation, income, and history of medications taken. Relevant data were collected by reviewing the participants' medical records. The questions on the questionnaire were grouped into four subsections, namely Section A: Sociodemographic data, Section B: Knowledge of HIV/AIDS and ART, Section C: Level of adherence to ART, and Section D: History of medication taken.

Collection stool and blood samples

Stool samples were collected from participants into a sterile, sealed universal container given to each of the participants and transported immediately to the Microbiology and Parasitology Unit of the University of Calabar Teaching Hospital Laboratory, Calabar, Nigeria, for analysis.

Five milliliters of blood samples was also collected from the participants into ethylenediaminetetraacetic acid (EDTA) container for algorithm of HIV testing and the determination of hemoglobin level.

Laboratory analysis of stool and blood samples

Stool samples were examined macroscopically in the laboratory to check for color, consistency and presence of blood, mucus, and worms in the stool samples. The stool samples were analyzed microscopically to using wet preparation, formol–ether concentration, and modified Ziehl–Neelsen method in order to detect the enteric parasites.[10]

HIV screening was done using the serial algorithm of screening with a determined and confirmed result with Unigold as described by the Centers for Disease Control and Prevention.[11] Cyanmethemoglobin method was used to determine the hemoglobin level of the patients, and this was done as described by Dacie et al.[12]


CD4 count was analyzed using Partec CyFlow counter made in Germany. Briefly, 20 μl fresh whole EDTA blood was added to 20 μl CD4/MAb in a test tube and incubated in the dark at room temperature for 15 min, and 800 μl of buffer was added, connected to the CyFlow, and allowed to run. Automatically generated report of the blood sample was displayed on the screen of the machine.[13]

Statistical analysis

Data collected were analyzed using SPSS Statistics 20 manufactured by International Business Machines (IBM Corp, Armonk, New York). Mean and standard deviation were used to describe continuous variable, and proportion was used for categorical ones. The difference in ova count and hemoglobin levels was determined by independent t-test, and the proportion of infection of the participants was determined by the Chi-square test. P < 0.05 was considered statistically significant.

Ethical approval

The ethical approval was sought for and obtained from the Cross River State Health Research Ethics Committee of the Cross River State Ministry of Health, Nigeria, on May 1, 2017. A written consent form was also duly signed by the participants.


[Table 1] presents the distribution of the participants based on their sociodemographic characteristics. Out of the 350 people living with HIV in the study, most participants were between the ages of 30-39 years with 31.14% (109/350) while 5.43% (19/350) were between the ages of 10-19 years. Majority of the participants were females with 65.14% (228/350) while 34.86% (122/350) were males; 42.29% (148/350) of the participants had tertiary education while 2% (7/350) had quaranic education; 31.43% (110/350) of the participants were unemployed while 14% (49/350) were public servants; 46.86% (164/350) were married while 9.43% (33/350) were divorced; and 58.57% (250/350) of the participants were poor income earner while 3.14% (11/350) were lower-middle income earners.{Table 1}

The distribution of participants as per awareness about HIV and its modes of transmission is presented in [Table 2]. Most participants at 99.43% (348/350) were aware of the HIV virus while 0.57% (2/350) were ignorant of the virus. Most of the participants were knowledgeable that the virus is transmitted through sexual intercourse at 97.14% (340/350); 46% (161/350) were aware that the virus could transmitted through blood transfusion; 51.43% (180/350) were aware that the virus could be transmitted through sharp objects; while 34.29% (120/350) knew that it could be transmitted from mother to child.{Table 2}

[Table 3] shows the distribution of the participants based on their gender and adherence to therapy. A total of 79.43% (278/350) participants were adherent to ART with 65.83% (183/278) of the female participants were adherent to ART while 34.17% (95/278) male participants were adherent. The percentage of the female participants who were not adherent were 62.5% (45/72) while 37.5% (27/72) of the male participants were not adherent which implies that a total of 20.57% (72/350) were non-adherence. The difference in adherence between the male and female participants was not statistically significant (P > 0.05).{Table 3}

[Table 4] explains the distribution of participants according to the predominant cause of nonadherence to therapy. It was observed that stigma accounted for the most reason for non-adherence with 34.57% (121/350) while ARV being out of stock at the hospital accounted for the least reason for non-adherence with 4% (14/350).{Table 4}

In [Table 5] where the distribution of the participants by CD4 counts and adherence to therapy is presented, most of those who adhered to ART regimens at 47.84% (133/278) accounted for CD4 counts between 201–400cell/μl while 6.47% (18/272) accounted for CD4 counts of >801cell/μl. Among the participants who did not adhere to ART regimens, 50% (36/72) recorded CD4 <200cell/μl while 2.78% (2/72) recorded CD4 counts >801cell/μl.{Table 5}

[Table 6] shows the enteric parasite loads and hemoglobin level of the participants based on adherence to therapy. Out of the 278 participants who adhered to ART, 9.35% (26/278) were infected while 18.06% (13/72) of the 72 participants who did not adhere to ART were infected. The difference in infection based on adherence was not statistically significant (P > 0.05).{Table 6}

The mean enteric helminth ova count among those whose adhered to ART was 452.23+38.25ova/g of stool while that of those who did not adhere to ART was 482.37+77.67ova/g of stool. The difference in ova counts between those adhered and those who did not adhere to ART was statistically significant (P = <0.0001).

The mean haemoglobin level of those who adhered to ART was 10.41+0.40g/dl while the mean haemoglobin level of those who did not adhere to ART was 9.05+0.53g/dl. The difference in haemoglobin level between those who adhered to ART and those who did not adhere was statistically significant (P = <0.0001).


The ultimate goal of treatment with ART is to minimize the effects of HIV to an undetectable level and maintain such subsidence without interruption.[14] It has been reported that adherence to ART is of significant importance because a minor deviation from the prescribed ART regimen may result in failure in the prescribed therapies and increase in viral resistance.[15]

The results of this study show that the level of awareness of both HIV/AIDS and ART among the participants was high. The level of nonadherence of 20.57% (72/350) was lower than 45.2% reported by Chineke et al.,[16] 75.0% reported by Golin et al.,[17] and higher than 5.0% of nonadherence as reported by Walsh et al.[18] In the present study, stigma accounted for the most reason for nonadherence among the participants. This observation differed from that of Chineke et al.[16] and Golin et al.[17] who reported that self-discouragement was the reason for nonadherence.

The high level of awareness on HIV/AIDS and the high level of adherence to ART might be attributed to the level of education of the participants as most of the participants had at least secondary school education. The high level of adherence among the female participants (65.83%) as revealed in this study was similar to that of Chineke et al. who reported 56.3% adherence to ART among the females.[16] However, it is different from the observation of Hogg et al. and UNAIDS who both reported that females had low level of adherence due to ART side effects.[19],[20]

Socioeconomic status of the participants did not have any effect on the level of adherence. ART drugs are supplied free of charge. However, low socioeconomic status may increase the rate of death from HIV/AIDS as earlier reported by Chineke et al.[16] and Palella et al.[21] Among those who did not adhere to treatment, 50% of them had CD4 counts of <200 cell/μl, whereas 47.84% (133/278) of those who adhered to treatment had CD4 counts of 200–400 cell/μl. This agreed with the reported of Bangsberg et al. who affirmed that patients with minimal transition to AIDS become stronger, happier, and healthier.[22]

In this study, the rate of infection with enteric parasites among participants who did not adhere to ART was 18.06% (13/72) and was higher than 9.35% (26/278) in those who adhered to the therapy. This agreed with that of Pennap et al.[23] and that of Missaye et al.[24] who reported a significant rate of infection of enteric parasites among participants who did not adhere to ART than those who adhered to ART. This is possible because ART has been reported to protect parasitic infection by inhibiting their aspartyl protease and building of the patient's immune system.[24]

Participants who adhered to ART recorded a higher hemoglobin level of 10.41 ± 0.40 g/dl than 9.05 ± 0.53 g/dl in those who did not adhere to ART in this study. This agreed with that of Gedefaw et al. who reported a higher hemoglobin level among participants who adhered to ART than among participants who did not adhere to ART. Although low hemoglobin level is a multifactorial condition which could have been attributed to effects of infections, malignancy, malnutrition, and polypharmacy, the variation in hemoglobin levels between these two groups may indicate the effectiveness of ART in those individuals.[25]


Clinicians should develop a close interpersonal relationship with the patients on ART to enable them monitor their level of adherence to ART regimen in order to set up strategies that will help improve their drug regimen. Further in-depth studies should be conducted involving a larger number of participants and a wider area of study setting.


The authors wish to thank all the participants in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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