TAF Preventive Medicine Bulletin, 2010: 9(3)
Araştırma/Research Article
TAF Prev Med Bull 2010; 9(3):201-208
Knowledge of and Attitude towards Antiretroviral Therapy among People Living with HIV/AIDS in Nigeria [Nijerya’da HIV/AIDS Taşıyanların Antiretroviral Terapi ile İlgili Tutum ve Bilgi Düzeylerinin Araştırılması] SUMMARY AIM: This study was aimed at determining the knowledge of and attitude towards ARV therapy among People Living with HIV/AIDS (PLWHA) in Ife-Ijesa zone of Osun State, south west Nigeria. METHOD: One hundred and twenty subjects who received ARV drugs at the Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife (OAUTHC) and Living Hope Care, Ilesa (LIHOC) were recruited and studied. Relevant data were collected using an interviewer-administered, semi-structured questionnaire. Focus group discussions (FGD) were also held among the subjects to further elicit qualitative information on the knowledge and attitude towards ARV. RESULTS: The age of respondents ranged from 21 to 65 years with a mean age of 40.2±10.3 years. Majority (70.8%) were aged 15 to 44 years, with a female preponderance (male to female ratio of 1:1.9). Respondents had been on ARV drugs for a period ranging between 3 and 60 months. A majority (80.8%) of the PLWHA had good knowledge of ARV drugs while a sizeable proportion (77%) of them demonstrated a positive attitude towards it. Majority of FGD participants reported missing doses of ARV due to forgetfulness, hiding the drugs because of stigma and lack of funds. Marital status, level of education, religious affiliation and regular attendance at support group meeting were significantly associated with good knowledge of and positive attitude towards ARV while duration of commencement of ARV was only significantly associated with positive attitude towards ARV. CONCLUSION: PLWHA in Ife-Ijesa zone of Osun State demonstrated good knowledge of ARV therapy and also displayed a positive attitude towards it. There is a need to reinforce these factors, so that it can translate to good ARV adherence. ÖZET AMAÇ: Bu çalışmada, Nijerya’nın batısında bulunan Osun eyaletinin Ife-Ijesa bölgesinde yaşayan HIV/AIDS’li insanların (PLWHA) ARV tedavisi konusundaki tutum ve bilgi düzeylerini değerlendirilmesi amaçlanmıştır. METOD: Araştırmanın katılımcılarını Ile-Ife (OAUTHC)’de bulunan Obafemi Awolowo Üniversitesi Eğitim Hastanesi ve Ilesa (LIHOC)’de bulunan Living Hope sağlık merkezinde ARV tedavisi verilmiş 120 gönüllü hasta oluşturmaktadır. Veriler anketör kullanılarak toplanmış, yarı yapılandırılmış anket formu uygulanmıştır. Katılımcılar arasında ARV hakkındaki bilgi düzeyi ve tutum konusunda bulunabilecek diğer niteliksel bilgilere ulaşmak amacıyla Odak grup tartışmaları düzenlenmiştir. BULGULAR: Katılımcıların yaşları 21 ile 65 arasında olup yaş ortalaması 40,2±10,3’dür. Çoğunluk 21 ile 65 yaşları arasında olup kadın katılımcıların sayısı daha fazladır (erkek kadın oranı 1:1,9). Katılımcıların ARV kullanım süreleri 3, ile 60 ay arasındadır. HIV/AIDS’li hastaların çoğunluğu (%80,8) ARV hakkında yeterli bilgiye sahiptir, önemli bir kısmı ise (%77) pozitif tutum göstermektedir. FGD katılımcılarından elde edilen bilgiler ışığında ARV ilaçlarının alınmama sebeplerinin unutma, ilaç yan etkilerinden dolayı almama ve ilaç almak için yeterli paranın olmaması olduğu saptanmıştır. Medeni durum, eğitim seviyesi, dini eğilimler ve grup çalışmalarında düzenli olarak bulunma ARV tedavisi konusundaki bilgi düzeyleri ile anlamlı ilişki içerisinde olduğu, ARV tedavisi konusundaki pozitif tutumun ise yalnızca ARV’ye başlama zamanı ile anlamlı ilişkisinin bulunduğu saptanmıştır. SONUÇ: Osun eyaletinin Ife-Ijesa bölgesinde yaşayan PLWHA’larda ARV tedavisi ile ilgili bilgi ve pozitif tutum düzeyinin iyi seviyede olduğu değerlendirilmiştir. ARV tedavisi ile ilgili bilgi ve pozitif tutum konularında sağlanacak gelişmeler, ARV tedavisinin daha iyi sonuçların alınmasını sağlayacaktır.
INTRODUCTION HIV/AIDS represents a major public health issue in Nigeria, as of more than other countries of the world. Since it was first reported in 1986, it has spread nationwide. The current prevalence is 4.4% and infection rate is as high as 12% in some parts of the country. Nigeria is in the midst of a potential crisis, www.korhek.org
Muhammed Olanrewaju Afolabi1, Kayode Thaddeus Ijadunola2, Adesegun Ola 2 Fatusi , 3 Olayinka Olasode 1
Department of Family Medicine, Ladoke Akintola University Teaching Hospital, Osogbo, Nigeria, 2 Department of Community Health, 3 Department of Dermatology & Venereology, Obafemi Awolowo University, IleIfe, Nigeria. Key Words: Knowledge, Attitude, ARV, PLWHA, Nigeria. Anahtar Kelimeler: Bilgi Düzeyi, Tutum, ARV, PLWHA, Nijerya. Sorumlu yazar/ Corresponding author: Muhammed Olanrewaju Afolabi, Department of Family Medicine, Ladoke Akintola University Teaching Hospital, PMB 5000, Osogbo, Osun State, Nigeria.
[email protected]
facing the real possibility of rates escalating to levels seen in southern Africa, unless treatment and prevention activities are greatly enhanced. This imperative to address HIV/AIDS treatment in developing countries has become more urgent as the burden of AIDS mortality has shifted to the poorest and most marginalized segments of the globe (1).
201
TAF Preventive Medicine Bulletin, 2010: 9(3) Effective HIV/AIDS care requires antiretroviral therapy as a treatment option. Without access to antiretroviral therapy, people living with HIV/AIDS may not attain the fullest possible physical and mental health (2). Current Public Health Service (PHS) guidelines recommend that patients should be treated with combinations of three to four antiretroviral drugs, with at least two of the three available classes of drugs represented in the regimen, that is, nucleoside reverse transcriptase inhibitors [NRTIs], non-nucleoside reverse transcriptase inhibitors [NNRTIs], and protease inhibitors [PIs] (3). Most combinations include a backbone of nucleoside agents used in conjunction with NNRTIs and/or protease inhibitors. On one hand, selection of ARV treatment regimens for individual patients put into consideration potency, frequency of dosage and sideeffects; which are known to influence adherence of the patient population to a regimen. On the other hand, adherence to medication is influenced, among other factors by the knowledge of and attitude towards the drugs. Medication adherence, particularly for complex regimens such as highly active antiretroviral therapy (HAART), is a complex behavior, requiring patients to remember multiple medications and dosing schedules (4). A theoretical framework encompassing cognitive factors has been suggested by researchers who assert that health behavior modification like ARV adherence requires knowledge, skills, and self-efficacy (5). Knowledge has been defined variously as awareness of personal health status (6) as well as general knowledge of the afflicting condition (7). Studies have also reported that understanding of medication effectiveness is associated with better adherence (8), while inadequate knowledge and confusion have been associated with lower adherence (9). In contrast; some studies have described no significant lasting benefits of knowledge upon adherence (7). In Nigeria and other African countries, several studies have reported the relationship of knowledge with adherence to medications in patients with chronic diseases such as hypertension and diabetes mellitus. However, there is a paucity of data on knowledge and attitude of PLWHA on ARV. This study sets out to address this gap. This assessment of knowledge and attitude of PLWHA about ARV may provide the platform for future interventions to improve adherence to this type of therapy especially in resource-limited setting like Nigeria.
MATERIAL AND METHOD
202
Study Location: The study was conducted in Ile-Ife and Ilesa: two adjoining towns in Osun State, Southwest of Nigeria. The HIV prevalence of Osun State was estimated at 1.2%, based on the 2007 sentinel survey report (10). The state has two ARV treatments centre serving sixteen neighbouring towns and cities. Study Design: The study employed a cross-sectional, descriptive design. Study Population: This included patients that were confirmed positive for HIV and were receiving antiretroviral drugs in the two recognized ARV treatment centers located in Ife-Ijesa zone of Osun State. The zone has two units of the Obafemi Awolowo University Teaching Hospital, Ile-Ife which is one of the treatment centers approved by Federal Government of Nigeria. Though, ARV drugs are free from the Federal Government, beneficiaries are expected to undergo mandatory laboratory investigations before commencement of the medication. These investigations cost about thirteen thousand naira (about US$104), and are repeated every three months to monitor progress of the patients on the ARV drugs. Living Hope Care, Ilesa (LIHOC) is a nongovernmental, community based organization that provides comprehensive care and support for PLWHA. The organization is situated in Ilesa and collaborates with one of the US President’s Emergency Plan for AIDS Relief (PEPFAR) sites located within the Nigerian Institute of Medical Research, Lagos. Clients from LIHOC access ARV from PEPFAR facility in Lagos. The laboratory investigations as well as ARV drugs are provided at no cost to clients from LIHOC, Ilesa. The clients only need to provide one thousand naira (about US $8) as transport fare to convey them to and fro NIMR, Lagos. Apart from ARV treatment, the PLWHA were organized into support groups which meet every fortnight to share experiences and discuss issues that affect them. The investigator attended a number of such meetings in Ile-Ife and Ilesa. Sampling Technique: Participants were serially recruited into the study over a 4 month period. All PLWHA were eligible to participate, except those that satisfied the exclusion criteria. These included PLWHA that were yet to commence ARV drugs, those that were acutely ill or those that refused to grant a consent for the study. Data Collection Instruments: Data were collected using quantitative and qualitative techniques. Quantitative instrument consisted of a semistructured, interviewer-administered questionnaire that has sections on socio-demographic data, knowledge and attitude towards ARV. Questions that www.korhek.org
TAF Preventive Medicine Bulletin, 2010: 9(3) assessed the knowledge included whether participants had heard about ARV drugs before, the sources of information about ARV, types of ARV drug combinations they knew, the right time to commence ARV, possible consequences of not adhering to ARV as well as whether there were alternative medications to ARV drugs. Questions bothering on attitude examined if they would like their spouses, children, friends, relations or co-workers know they were taking ARV medications and what their behaviour might be if these group of people accidentally found out they were on ARV medication. These questions were pre-tested among a cohort of 5 PLWHA who did not participate in this study. A re-test was conducted among another group of PLWHA and the questions were found to be satisfactory before administered among study participants. To ensure in-depth exploration of respondents’ knowledge and attitudes of PLWHA towards ARV drugs, two Focus Group Discussion (FGD) sessions were held each in Ife (male and female groups) and Ilesa (male and female groups) using a purposedesigned FGD guide. The investigator served as the facilitator for the FGD. Data Analysis: Quantitative data were analyzed using SPSS for Windows software version 11. Frequency and percentage of variables were estimated. To obtain an objective assessment of the levels of knowledge and attitude ratings of study participants, the responses to the questions that assessed knowledge and attitudes of the PLWHA were scored. Each correct answer to a knowledge question attracted one mark while wrong answers were scored zero. Scores obtainable ranged from 0 to 10. Summated scores were used to assess the knowledge of the PLWHA about ARV. For the purpose of this study, a score of 0 to 3 was rated poor, 4 to 6 was rated fair, while 7 to 10 was rated good knowledge of ARV. For the attitude of PLWHA towards ARV, scores obtainable also ranged between 0 and 10. A score of 0 to 4 was rated negative attitude while 5 to 10 was rated positive attitude towards ARV therapy. Qualitative data gathered from focus group discussions were analyzed through detailed content analysis and ethnographic summary. This involved verbatim quoting of respondents to buttress certain arguments raised in the course of discussion. Quantitative and qualitative data were triangulated in the report.
www.korhek.org
Ethical Clearance and Consent: Ethical clearance was obtained from the Research and Ethical committee of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. Informed written consent was obtained from each participant before the interview.
RESULTS A total of one hundred and twenty (120) PLWHA receiving antiretroviral (ARV) drugs at the Obafemi Awolowo University Teaching Hospital, Ile-Ife (OAUTHC) and Living Hope Care (LIHOC), Ilesa were studied. Fifty subjects (41.7%) were recruited from OAUTHC, Ile-Ife, while seventy subjects (58.3%) were recruited from LIHOC, Ilesa. The ages of respondents ranged between 21 and 65 years with the mean age of 40.2±10.3 years. There were 79 females (65.8%) and 41 males (34.2%) with a male to female ratio of 1: 1.9. The modal age group was 35 44 years, representing 41% of the study population. The participants had been on ARV drugs for a period ranging between 3 and 60 months and the mean period of commencement of ARV was 16.9±12.3 months. A majority (52.5%) of the respondents were currently married. A sizeable proportion (37.5%) of them had no formal education, while 50% were artisans. About eighty three percent were Christians and 54 % attended support group meetings regularly. Figure 1 shows that a majority 97 (80.8%) of the PLWHA had good knowledge of ARV, while only 4 (3.3%) of them had poor knowledge of ARV drugs Figure 2 shows that a majority of the subjects demonstrated positive attitude towards ARV therapy, while only 23 % had poor attitude. The findings from quantitative data were buttressed by reports from the FGD sessions. A majority of the FGD participants demonstrated a good level of knowledge of ARV therapy. All of them overwhelmingly believed that ARV is efficacious in reducing viral load. A male participant from Ilesa observed thus: “Before starting ARV, I was very lean; my neighbours were suspecting that I had HIV. They even concluded that the disease may be responsible for the death of my wife; but as soon as I started using the drug, I started gaining weight and the suspicion was put off”
203
TAF Preventive Medicine Bulletin, 2010: 9(3)
90
80.8
80 70 60 50 Series1
40 30 15.9
20 10
3.3
0 good knowledge
fair knowlegde
poor knowledge
Figure 1. Bar chart showing level of knowledge of study participants about ARV drugs.
23% negative attitude positive attitude 77%
Figure 2. Pie chart depicting attitude of PLWHA in Ife-Ijesa zone of Osun State towards ARV
204
www.korhek.org
TAF Preventive Medicine Bulletin, 2010: 9(3) Table 1. Distribution of socio-demographic characteristics and levels of knowledge among study participants
Characteristics
Good knowledge n= 97
Fair knowledge n=19
Poor knowledge n= 4
Age group Less than 45 years 45 years and more
72 (74.2) 25 (25.8)
11 (57.9) 8 (42.1)
2 (50.0) 2 (50.0)
Duration of commencement of ARV Less than 12 months 12 months and more
30 (30.9) 67 (60.1)
7 (36.8) 12 (63.2)
1 (25.0) 3 (75.0)
Marital Status Never married Currently married Out of marriage
4 (4.1) 55 (56.7) 38 (39.2)
9 (47.4) 6 (31.6) 4 (22.0)
1 (25.0) 2 (50.0) 1 (25.0)
Level of education Had no formal education Had formal education
27 (27.8) 70 (72.2)
15 (78.9) 4 (21.1)
3 (75.0) 1 (25.0)
Occupation Currently employed Unemployed
29 (29.9) 68 (70.1)
6 (31.6) 13 (68.4)
3 (75.0) 1 (25.0)
Religious affiliation Christianity Islam
85 (87.6) 14 (12.4)
17 (63.2) 7 (36.8)
2 (50.0) 2 (50.0)
Regular support group attendance Yes No
57 (58.8) 40 (41.2)
5 (26.3) 14 (73.7)
3 (75.0) 1 (25.0)
p-value
χ² =2.82 p=0.09
χ² =0.13 p= 0.72
χ² =27.96 p =0.000009*
χ² =21.08 p=0.0001* χ² =0.73 p=0.392 χ² =9.22 p=0.0024*
χ² =4.31 p=0.04*
* Yates’ corrections applied. Table 1 shows that marital status, level of education, religious affiliations and regular attendance at support group meetings had significant associations with the level of knowledge of study participants about ARV drugs.
A majority of the participants also admitted that non-adherence to ARV would eventually lead to manifestation of opportunistic infections which may lead to death. A female participant from Ile-Ife said: “I have come across people with diseases like TB and other serious problems which I think was caused by not taking ARV regularly. Those of us taking the drugs are looking healthy. You can see for yourself” This implies that the disease characteristic also helps in shaping people behaviour. Thus, most of the participants were aware of the consequences of not taking ARV and the valued efficacious action of the drugs. Another female participant from Ile-Ife remarked:
www.korhek.org
“Anybody that has witnessed some of the complications of HIV/AIDS will have respect for ARV. At least, we have attended the funeral of some of our colleagues and we don’t want our own death to come now.” Although, a few of the FGD participants believed that there was a cure for HIV/AIDS somewhere which was not yet discovered, it was generally agreed that HIV/AIDS is not curable and the only therapeutic regimen available is ARV which prolongs life while living with the virus. One male participant from Ilesa lamented thus:
205
TAF Preventive Medicine Bulletin, 2010: 9(3) Table 2. Distribution of socio-demographic characteristics and attitude rating among study participants Positive attitude n=92
Negative attitude n=28
p-value
72(78.3) 20 (21.7)
20 (71.4) 8 (28.6)
χ² =0.56 p=0.456
20 (21.7) 72 (78.3)
12 (42.9) 16 (57.1)
χ²=4.90 p=0.03
4 (4.4) 58 (63.0) 30 (32.6)
10 (35.7) 5 (17.9) 13 (46.4)
χ² =27.6 p <0.00001
30 (32.6) 62 (67.4)
15 (53.6) 13 (46.4)
Occupation Currently employed Unemployed
77 (83.7) 15 (16.3)
5 (17.9) 23 (82.1)
χ² =40.01 p<0.00001
Religious affiliation Christianity Islam
78 (84.8) 14 (15.2)
21 (75.0) 7 (25.0)
χ² =0.83 p=0.363
56 (60.9) 36 (39.1)
9 (32.1) 19 (67.9)
χ² =7.14 p=0.008
Characteristics Age group Less than 45 years 45 years and more Duration of commencement of ARV Less than 12 months 12 months and more Marital Status Never married Currently married Out of marriage Level of education Had no formal education Had formal education
Regular support group attendance Yes No
χ² =4.02 p=0.04
Table 2 shows that duration of commencement of ARV drugs, marital status, level of education, occupation and regular attendance at support group meetings are significantly associated with attitude ratings of study participants towards ARV drugs
“It is rather sad and unfortunate that a cure has not been found for the deadly disease, despite all the noise and research works on HIV. Well, I am still optimistic that a cure will be found very soon.”
DISCUSSION This study was designed to assess ARV knowledge and attitudes among PLWHA for the purpose of identifying behavioural factors that may influence adherence to ARV. ARV knowledge in this population is remarkably high which is reaffirming and important for achieving a high adherence to
206
ARV. Findings revealed that knowledge of ARV drug combinations, appropriate time to commence ARV, benefits of taking ARV regularly and possible results of not adhering to ARV medications were high among all the participants. Few of them claimed that there were potent alternative drugs to ARV while majority agreed that good adherence to ARV caused weight gain, improved quality of life and poor adherence may lead to death. Similarly, findings of this study also showed that majority of the participants would want their spouses, children and relations to know that they were taking ARV drugs. This is very unlike many studies which reported that many PLWHA would not take ARV
www.korhek.org
TAF Preventive Medicine Bulletin, 2010: 9(3) regularly because they hide the drugs from close family members (6-9). This may imply that significant number of the participants in this study seemed to have overcome the negative feelings associated with stigma and discrimination with ARV drug use or their family members were well enlightened to be less discriminating. Majority of the participants admitted that they sometimes forget to take the medications and rarely stop it when they feel better. At the focus group discussions, the participants demonstrated an overwhelming perceived efficacy of the drugs. This supports the findings of Kleeberger et al (13). that perceived efficacy of a drug is an important factor influencing its adherence. Furthermore, perceived efficacy of ARV is said to promote positive attitude (14). and this may explain why majority of subjects demonstrated a positive attitude towards ARV therapy. Many of the respondents reported an improvement in their health status following commencement of ARV. This general health improvement strengthened their beliefs in the treatment regimen and this also served as motivation to continue its usage. Acknowledging the incurability of HIV/AIDS by a majority of respondents and cues to action like witnessing the death of a colleague may also promote adherence to ARV. In addition, socio-demographic factors like marital status, level of education, religious affiliation and regular attendance at support group meetings were significantly associated with good level of knowledge about ARV. This may be explained by the interplays of social dynamics that contribute to obtaining correct health information. Majority of the participants were in a stable marriage and had formal education; they also attended the support group meetings where regular psycho-social counseling and health education were performed. A similar association was found between good attitude towards ARV and these socio-demographic factors. Expectedly, duration of commencement of ARV was significantly associated with attitude rating of the participants. This may be due to adjustments of the PLWHA to the medications after a long period. However, time factor was not significantly associated with level of knowledge, probably because knowledge, unlike attitude is dynamic and needs to be updated with changing trends of new discoveries in HIV medicine. This study is important because Nigeria has one of the highest numbers of PLWHA in the world, and most of the PLWHA accessing ARV need to have good knowledge and positive attitude towards the drug therapy in order to maximize its benefits. The strength of this study lies in the fact that qualitative www.korhek.org
and quantitative instruments were used to obtain data from the participants. This assisted in highlighting important factors which may not be effectively touched by using only one method of data collection. However, there are some limitations to the findings of this study. First, the sample size is relatively small, including only 120 subjects. Second, these PLWHA came from two large towns, Ilesa and Ife, and may not reflect the knowledge and attitudes of those in more remote areas. Finally, a validated instrument assessing knowledge and attitude was not employed in this study. This indicates the need to develop an objective tool which can be adapted to African context to assess the knowledge and attitude towards ARV. In conclusion, PLWHAs in Nigeria demonstrate a high level of knowledge, pragmatic attitude, and conscientious behavior about ARV. This study uniquely highlights issues specific to developing countries in Africa. Also, the psychosocial and adherence counseling at the support group meetings are effective and instill positive attitude in patients so as to optimize the benefits of ARV. Furthermore, the support group contributes to an open atmosphere where PLWHA are encouraged to discuss and find solutions to issues affecting them. Medication adherence can be achieved by reinforcing through patient education and counseling, much of the information concerning HIV and ARV drugs which many PLWHA already know. It is recommended that these issues should be decisively appraised so that the optimum benefits of ARV drug therapy can be achieved. REFERENCES 1.
Carmody ER, Diaz T, Starling P, Santos APRB, Sacks HS. An evaluation of antiretroviral HIV/AIDS treatment in a Rio de Janeiro Public clinic. Tropical Medicine and International Health. 2003; 8(5): 378-385.
2.
UNAIDS. Report on the Epidemic. Geneva. 2002.
3.
World Health Organization and UNICEF. Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections in Nigeria. Update. Geneva. 2002.
4.
Whitley HP, Fermo JD, Ragucci K, Chumney EC. Assessment of patient knowledge of diabetic goals, self-reported medication adherence, and goal attainment. Pharmacy Practice. 2006; 4(4): 183-190.
5.
Cervone D. Thinking about self-efficacy. Behavior Modification. 2000; 24(1): 30-56.
Global
HIV/AIDS
207
TAF Preventive Medicine Bulletin, 2010: 9(3) 6.
Tovar E, Durvasula RS. (2002) Beliefs, knowledge, self-efficacy and medication adherence_in_HIV(+)_women._http://www.calstat ela.edu/academic/psych/ftp/TovarPoster1.ppt [Accessed August 23, 2009].
7.
Sorenson JL, Mascovich A, Wall TL, DePhilippis D, Batki SL, Chesney M. Medication adherence strategies for drug abusers with HIV/AIDS. AIDS Care. 1998; 10(3): 297-312.
8.
Bennet SJ, Lane KA, Welch J, Perkins SM, Brater CD. Medication and Dietary Compliance Beliefs in Heart Failure. Western Journal of Nursing Research. 2005; 27(8): 977-993.
9.
Au J. Knowledge, attitude, and behavior of HIV patients on antiretroviral therapy. IAS 2005 Conference HIV Pathogenesis & Treatment. Abstract No. TuPe11.9C08.
10. National Action Committee on AIDS. HIV Sentinel Survey Surveillance among high risk population in Nigeria. Abuja, Nigeria. 2007. 11. Federal Ministry of Health. Department of Public Health, National AIDS/STD Control Programme: A Technical Report on the 2001 National HIV/Syphilis sentinel survey among pregnanat women attending antenatal clinics in Nigeria. 12. Federal Ministry of Health. HIV/AIDS: What it is meant for Nigeria–Background, Projection, Impact. Intervention and Policy. Abuja. 2002. 13. Kleeberger CA, Phair JP, Strathdes SA. Determinants of heterogenous adherence to HIV antiretroviral therapies in the multi-center AIDS cohort study. Journal of Acquired Immune Deficiency Syndrome. 2001; 26: 86-92. 14. Chesney MA. Factors affecting adherence to antiretroviral therapy. Clinical Infectious Diseases. 2000; 30(Suppl 2): 171-6.
208
www.korhek.org
