Social and health system barriers to adherence to antiretroviral therapy (ART) among adolescents 10-19 years in differentiated service delivery (DSD) models in Tororo district, Eastern Uganda.

Abstract

Introduction Adherence to ARVs among young people aged 10 to 19 years remains low in Uganda and therefore a contributing factor to non-achievement of the third 95; that is, 95% of those on ART treatment being virally suppressed. Differentiated Service Delivery (DSD) models were introduced to reduce burdens on the already strained health systems and promote a greater use of community-based approaches in promoting HIV treatment. This was to be achieved within supportive social environments for better viral suppression through good adherence and good health for all HIV positive persons on ART. Study aim; This study aimed to assess adherence levels and associated factors and to explore social and health systems barriers to ART adherence among adolescents 10 to 19 years in DSD models in Tororo District. Method A mixed methods study was conducted, using both quantitative and qualitative methods to collect data. Through review of clients’ medical records, secondary data abstraction was carried out, and primary data collection was done through in-depth-interviews with adolescents and key informant interviews with health workers who worked in ART clinics. A total of 313 participants were randomly selected using systematic random sampling to participate in the study. Convenient sampling was used to select 30 adolescents with average/poor adherence levels, to explore their perceptions on social barriers to adherence to ART. Key informant interviews were conducted with 15 health care workers who had worked under the DSD to explore their perspectives on health system barriers to adherence to ART among adolescents in DSD models in Tororo District. Modified poisson regression was used for bivariate and multivariate analysis at 0.05 level of significance for quantitative data. For qualitative data, thematic content analysis was used for code generation into categories, sub-themes and themes. Results Overall, good adherence (≥95%) for all the five DSD models in the selected health facilites in Tororo District was optimal at 88.5%(CI 84.4-91.6) However, good adherence was universal (100%) for the three models Fast Track Drug Refill (FTDR), Community Drug Distribution Point (CDDP) and Community Client-Led ART Distribution (CCLAD), Poor adherence was found at 11.5%(CI 8.4-15.6) in Facility Based Individual Management (FBIM) and Facility Based Group Management (FBG). There was an association between adherence to ART and age, facility location, health status, ART regimen, and availability of treatment assistant. Adherence was significantly lower among participants age 15-17 years cPR:0.94(0.85-0.98) (p=1.04) and those on ABC/3TC/DTG treatment cPR: 0.81(0.67-0.97) (p=0.025). Barriers to ART adherence identified included; stigma and discrimination, cost of transport to the health facility and distance to the facility. The health system barriers to adherence included; limited follow-up from the facility, long waiting hours at the ART clinic drug regimen, healthworker knowledge and training among others. Conclusion In this study, good adherence levels were found to be high in less intensive DSD models and low in client-dense models of FBG and FBIM. The social and health system barriers mentioned can be addressed and modified in enhancing better adherence levels among adolescents in the affected models at both health facility and social/community levels in the District. Recommendations There is need to focus on addressing social support issues, stigma and discrimination, through health education and sensitization to families and the community to support good adherence to ART among adolescents in FBG and FBIM models especially in rural areas. There is need for for program re-evaluation and contextualization of facility based DSD models of FBG and FBIM in HIV care and support for adherence support among adolescents in Tororo District.