We found that the overall proportion of ART adherence measured by using the Morisky scale (52.3%) was lower than adherence measured by self-report (95%). The proportion of adherence to ART didn’t vary between those patients who started ART before the introduction of UTT strategy and patients who started ART after the introduction of UTT strategy. This study identified that depression, meal frequency and concomitant illness were factors associated with ART adherence.
This study revealed that the overall proportion of ART adherence measured by using the Morisky scale is lower than the proportion of ART adherence measured by using a seven-day patient self-report. The reason behind this difference could be self-report overestimate adherence since it is vulnerable to the dynamics of the provider-patient relationship and measurement biases like social desirability, recall and response bias (24). The overall proportion of ART adherence measured by using the Morisky scale is lower than the current recommended level of adherence by WHO (3). It is also lower than the proportion of ART adherence reported by a study conducted in Bale zone, Ethiopia(68.3%) which was measured by using four items MMAS) (7). The reason for this difference could be originally the four items Morisky medication adherence scale had low sensitivity (81%) and specificity (44%) to detect ART adherence and had 0.61 Cronbach’s alpha value, which is below the acceptable value of 0.7. Whereas the modified eight-item MMAS had high sensitivity (93%) and specificity (53%) with 0.83 Cronbach’s alpha value (25). Our finding is also lower than the proportion of ART adherence reported by a study conducted in India (78%), measured with the same scale (23).
The overall proportion of ART adherence measured by using seven-day patient self-report is consistent with the current WHO recommendation (3) as well as with a study conducted in Debre Birhan Referral Hospital(10).
Both Morisky scale and patient self-reports results showed that the proportion of ART adherence is not varying between patients who were enrolled before initiation of UTT strategy and patients who were enrolled after initiation of UTT strategy. This might be due to the reason that those patients who were enrolled before initiation of UTT strategy stay a long time on pre-ART which helped them to have good knowledge about adherence while those patients who were enrolled after initiation of UTT strategy could also be exposed to different media, educational materials and took an extensive adherence counseling that lead them to have similar ART adherence. This study also revealed comparable knowledge of HIV/AIDS and its treatment between those patients who initiated ART before (72.7%) and after (64.7%) the initiation of UTT strategy.
In this study, absence of depression was appeared to be positively associated with good ART adherence. Similarly, other literature showed that absence of depression was positively associated with good ART adherence (20,26,27). The possible reason for this might be that those patients who were not depressed might not experience hopelessness and demoralization which could in-turn prevent them skip or forget their regular treatment.
Meal frequency of three or more was also positively associated with good ART adherence. This finding is not in agreement with evidence obtained from Northern Ethiopia, in which daily eating pattern had no association with ART adherence(27). Though the causal mechanism is not clear yet, the association between reduced meal frequency and ART non-adherence might be because of perceived fear or actual experiences with increased hunger on ART when people have to take ART on an empty stomach. It might be also because of fear or actual experiences with exacerbated side effects of ART in the absence of adequate nutritional intake (28).
The absence of concomitant illness has been negatively associated with good ART adherence. Similarly, a study conducted in Bale zone, Ethiopia also revealed the absence of concomitant illness has been negatively associated with good ART adherence (7). This might be because of patients without concomitant illness reluctance to take their ART medication due to feeling well. On the other hand, patients with concomitant illness might adhere to their ART medication due to fear of death imposed by both HIV/AIDS and the concomitant illness. They might also stick to their ART medication because of having better information exposure about the importance of adhering ART medication as a result of double counseling service they might receive from different health care providers working for both HIV/AIDS and concomitant illness.
This study has strengths as well as limitations. As strengths, we used multiple ART adherence measurements. Adherence to ART was measured by patient self-report and the eight-item MMAS. In self-reported adherence, the last seven days ART adherence was used to minimize recall bias. As a limitation, adherence measured by the Morisky scale might be affected by recall bias as patients were asked to answer the questions by considering their medication intake since they start ART medication. Being a facility-based study can underestimate non-adherence because it is prone to miss defaulters and delayed visitors of their appointment.