HIV related stigma, depressive morbidity and treatment adherence in patients on antiretroviral therapy attending the Mwanayamala Hospital, Dar es salaam

Abstract

ABSTRACT Introduction: There are about 33 million people who are living with HIV and AIDS worldwide and approximately 67% are in sub Saharan African countries. In Tanzania 2 million people are living with HIV/AIDS and 30% of them are in need of antiretroviral treatment. Several studies highlighted some psychological experiences in people living HIV/AIDS including feelings of shame, guilt, helplessness, self-blame and self-isolation that suggest negative self-image and this negative self-image has influence on accessing medical care. Stigma and depressive morbidity related to HIV infection has serious individual and public health ramifications, including reluctance to testing for HIV, refusal to initiate treatment as well as poor treatment compliance and hence increased risk of HIV disease transmission and progression. No studies reported in Tanzania have systematically explored associations between HIV related stigma, depressive morbidity and uptake of medical recommendation hence limited local information is available for improvements in uptake of medical recommendations. Objectives: To determine the influences of HIV AIDS stigma and depressive morbidity on uptake of selected medical recommendations among persons living with HIV (PLHA) attending the Mwananyamala HIV and AIDS care and treatment clinic (CTC). Study design: Hospital based descriptive cross sectional study where quantitative methods were used to collect information. Methods: An Average of 6 per day of 370 randomly selected patients were invited to participate in the study then they were assessed, on socio demographic and socioeconomic measures, uptake of selected medical recommendations and depressive morbidity and vii HIV related stigma measures. Outcome measures included; antiretroviral adherence, defined as adequate if 95% or more medications were taken as prescribed in the past 4 days analyzed dichotomously; whether counseling sessions were attended or not during the index clinic visit and whether the last scheduled clinic visit was kept or not, also reported dichotomously and all summarized as simple frequencies. The predictors of interest explored were HIV related stigma and depressive symptoms. The magnitudes of stigma and depressive morbidity were computed using sum scores of responses; depressive morbidity was summarized as mild, moderate and severe and levels of stigma as tertiles. Logistic regression models using a backwards removal method were used to determine the strength of associations between the predictors of interest and the outcomes after adjusting for socio-demographic and economic confounders. Results: A total of 220 participants were included in the study, 69 (31.4%) being males and 151 (68.6%) females. Mean age (SD) was 35.5 (9.7) years with an age range of 18 to 68 years. All patients were on ART medication for not more than six months. The proportion non adherent to ART medication was 21.3%, and the proportion missing the last scheduled clinic visit was 19.1%. In linear regression analysis participants reporting divorce/widow (er) or cohabiting status were more likely to adhere to ART medication than those that were married (p value<0.01). In adjusted multivariate models, mild depressive morbidity was independently associated with non-adherence to the last scheduled clinic visit (OR 2.7; 95% confidence interval 1.02, 7.27; p<0.05) and attending individual counseling (OR 0.20; 95% confidence interval 0.05, 0.85 p <0.05) and was marginally associated with non adherence to ART medication (OR 2.6; 95% confidence interval 0.98, 6.82; p=0.06). Low level of stigma was independently associated with adequate adherence to ART medication (OR 3.00, 95% confidence interval 1.34, 6.91, p<0.01). No significant association was shown between internalized stigma and attending scheduled clinic visits or individual counseling during the index visit, or between depression and attending individual counseling sessions during the index visit. viii Conclusion and recommendations: Internalized stigma and depressive morbidity are challenges to the uptake medical of medical recommendations among PLHA. The study showed that PLHA who experience internalized stigma and depressive morbidity are more likely to be recently non-adherent to ART medications, while depressive morbidity influenced attending the last scheduled clinic visit. It is therefore recommended that interventions for recognition and management of both internalized stigma and depressive morbidity be a focus of the activities of health care workers in HIV and AIDS treatment clinics as one way of improving uptake of medical recommendations and including retention in HIV care and treatment.