The study found that 7.50% of patients had adherence level below the 95% adherence target. This non-adherence level is lower compared to findings from two recent studies conducted in Ethiopia (8, 15) and the central China (16).
This study found a strong association between non-adherence to ART and the category of patients aged 15–24 years, followed by forgetfulness, alcohol drinking, ALHIV with treatment interruption, and a shorter duration on ART.
The odds of non-adherence to ART among HIV patients aged between 15–24 years were 4.83 times higher compared to those aged 50 years and above. This corroborates with studies conducted in Ethiopia (17), and Haiti (18), which suggest that adherence levels increase as patients age beyond 25 years. Older patients may have better compliance with the regimen due to their familiarity with routines, maturity, and discipline. Therefore, targeting appropriate interventions toward young adult is essential.
The study also found that the odds of non-adherence among ALHIV who were on ART for less than five years were near three times higher than for those on ART for five years and above. The significant association between duration on ART, as determined in this study, is consistent with previous studies in Malawi, Haiti and Nepal (18–20), which emphasize that patients are more likely to be non-adherent at their early period of infection. Previous studies highlighted that this may be due to increased occurrence of opportunistic infections in early months of taking ART(6), however, this was not the same in our study. The reason of non-adherence to ART among patients in our study could be due to the concern of stigma and failure to adapt quickly with life change. In contrast to our study, a study conducted in the United States showed that patients who were on ART for five years and more were more likely to be non-adherent as compared to those who were on ART for less than five years(21). This difference between findings may be due the cultural differences and differences in health care infrastructure. Therefore, more intensive counselling and regular follow-up may better support HIV patients during their early stages of their medication regimen.
The finding of this study revealed that non-adherence was associated with forgetting to take prescribed medication. The odds of non-adherence among ALHIV who forgot to take their medication was more than four times higher than those who did not. This finding is consistent with several studies conducted elsewhere (5, 22–24), including Rwanda, where a study identified forgetfulness as one of the major causes of non-adherence (13). Patients often attributed forgetting to take their medications to the absence of someone to remind them about the drugs, and some linked forgetfulness to alcohol consumption (5). Hence interventions addressing this type of non-adherence may need to focus on providing reminders to patients to take their medications and supporting patients to make intake of medications part of their daily routine.
Our study found that the odds of non-adherence among adult HIV-infected people who drink alcohol was more than four times higher than those who do not. This is consistent with several studies, including a systematic review and meta-analysis conducted in Sub-Saharan Africa (25). Indeed, alcohol consumption is a common problem among PLWH (26), and research suggests that HIV-infected individuals, mostly men, may use alcohol to cope with the stress of being HIV-positive (27). Alcohol consumption contributes to non-adherence to ART, as it is disruptive to dose timing, not adhering to clinical and counselling advice, and interfering with normal social life (28). Also, excessive alcohol consumption can cause liver damage, and increase enzymes which leads to a shorter than expected drug half-life (29). The association between alcohol consumption and ART non-adherence underscores the need to prioritize alcohol counselling as priority of ART services to help HIV-infected patients to adhere to their medications, for longer and healthier lives.
This study also found that patients with treatment interruption had more than 4 times higher odds of non-adherence to ART than patients who did not. This finding is in line with a study conducted in Nigeria which revealed that patients who had treatment interruption are more likely to have poor adherence than patients who did not have ART interruption (30). In most studies, this interruption was attributed to the fact that patients want to have a break from treatment regimens due to treatment fatigue (31, 32). In this study, the association between non-adherence and treatment interruption may be attributed to duration on ART and distance to health facility as more than 70% of patients who had treatment interruption were on ART for more than 5 years and live in the distance of 2 km and above from the health facility. However, further investigation is warranted to find the tangible cause of non-adherence to ART in these patients as they receive more frequent clinical and counselling advice during their initiation to ART.
Limitations of the Study
Our study employed a combination of primary and secondary data collection methods to assess adherence to ART. Adherence was determined based on pill count data from the previous month, which may introduce recall bias among participants. To mitigate this potential bias, participants were provided with comprehensive information about the study's significance and the importance of providing accurate data. Data collection was conducted by trained healthcare professionals who received adequate training on the data collection process, ensuring the reliability and accuracy of the collected information. Furthermore, the generalizability of the study findings is limited to Nyamasheke district. However, our findings align with other studies conducted in Rwanda and elsewhere, suggesting similarities and potential applicability of the results to similar settings. Of course, it also represents limitations related to its cross-sectional design; especially the lack of causal relationship establishment.