FACTORS CONTRIBUTING TO A.R.T. DEFAULTING IN EASTERN REGION GHANA Clive Ashby. Ghana AIDS Commission

1. FACTORS CONTRIBUTING TO A.R.T. DEFAULTING IN EASTERN REGIONGHANAClive Ashby. Ghana AIDS Commission Ghana Eastern Region

2. ACKNOWLEDGEMENTS • Ghana AIDS Commission • Eastern Region Coordinating Council (ERCC) • Golda Asante & Kyeremeh Atuahene & Jewel Lamptey • HIV & AIDS focal persons in the Eastern Region • German International Cooperation (GIZ) • Centre for Migration & Development (CIM)

3. HIV & AIDS in Ghana • ANC prevalence : 2.0% • Estimated no. PLHIV : 221,941 PLHIV • Estimated no. new infections : 12,890 • No. AIDS-related deaths : 16,319 • Estimated in need of ART : 110,816 • Enrolled on ART : 61,393 (55.4%) • Unmet need : 49,423 (44.6%)

4. Upper East Upper West Northern Volta Brong-Ahafo Ashanti Eastern Western Central Greater Accra BURKINA FASO TOGO COTE D’IVOIRE Population = 2.4 million ANC prevalence = 3.2%

5. OBJECTIVES • Assess extent of ART defaulting • Identify patterns, frequency & duration of defaulting • Determine factors contributing to defaulting : - demographic - economic - medical/health - social factors - religious/cultural • Examine measures taken to reduce defaulting • Recommend future developments to reduce defaulting

6. ECONOMIC • Poverty • Transport Costs • User Charges • Food Insecure DEMOGRAPHIC • Age • Gender • Education • Marital Status MEDICAL • Service Provision • Understanding of ART • Adherence Monitoring • Time on ART • Side Effects • ‘Feeling Healthy’ RELIGIOUS/CULTURAL • Belief ‘Healed’ • Fasting • Prayer Camps • Traditional Medicine SOCIAL Stigma & Discrimination Social Support A.R.T DEFAULT

7. RESEARCH METHODS PLHIV Interviews • 379 ART patients • 1 : 1 Interviews • in 20 health facilities • in 14 districts Focus Group Discussions • 15 focus group discussions • PLHIV support groups • in 5 districts Key Informant Interviews • 97 Doctors, Nurses & Counsellors • in 20 Health Facilities • In 14 Districts TRIANGULATION of Results

8. FINDINGS • Extent • Patterns • Factors • Response

9. EXTENT of Defaulting • Observed by Health Professionals • 16.6 % (mean) PLHIV defaulted in last year • 9.6%(median) • Defaulting only observed when patient missed appt. • Reported by ART patients • 21.2% defaulted in last 6 months • 47.5% defaulted since starting ART

10. SO WHAT ? “Adherence to ART is well recognized as an essential component of individual and programmatic treatment success. Studies on drug adherence in the developed world have demonstrated that higher levels of drug adherence are associated with improved virological, immunological and clinical outcomes and that adherence rates exceeding 95% are necessary in order to maximize the benefits of ART” (WHO,2005)

11. FREQUENCY of Defaulting • Frequency of Defaulting reported by ART patients (64.6%) and health professionals (48.7%) was predominantly every few months

12. DURATION of Defaulting • ART patients interviewed : mostly one to several days (68.2%) • Health Professionals : mostly several weeks / months (70.7%)

13. REASONS for Defaulting

14. CONTRIBUTING FACTORS Only Factors significantly associated with Defaulting were Economic. i.e. Not having (a) regular employment; (b) regular meals; (c) appointment when cant pay.

15. FINANCIAL REASONS (FGD) “Most of the patients miss out in my opinion because of financial problems. A lot miss out up to one month; an example is a friend of mine from Bowdua who has to miss out for one full month because of money problems.” “As for me I come here with my wife but last week I could not raise enough money for both of us to come so I asked her to come and this week I am here to pick up for myself as well.”

16. USER CHARGES (FGD) Money to buy the drug is a problem, even though they say you can come for the drug without money, the pharmacist sometimes refuses to give it to us.” “So because of the money I have not been able to access the medicine because when you go, those who are supposed to give you the medicine tend to be abusive saying ‘just 5 cedis too you can’t pay’.” “The doctors sometimes instruct us to pay for three months who in turn gives us the drug for only one month. Some come from Cape Coast and Takoradi therefore how can you cope when the doctor tells you to pay for three month.”

17. TRANSPORT COSTS (FGD) “It’s easy for us to use the medication but difficult in terms of getting money to travel to the clinic to pick up refills. Even I had to borrow money to travel today. It’s really difficult in that sense especially for us who live in rural areas and have no good jobs. Last week I tried hard but could not come. Once I missed out for one full month and I nearly died.” “What my brother said is true. My wife and I both have to travel and it’s difficult for us. We were due to pick up medications last week but both of us could not travel together so she travelled alone to pick up and I am here this week to pick up medications. It’s so hard for us who do not have any work at all.”

18. RESPONSE – Health Facilities

19. CONCLUSIONS • Defaulting of approx. 16%– 22% (adherence of 78%-84% ) is insufficient to achieve maximum benefits of ART • Contributing Factors are predominantly Economic – i.e. lack of financial resources to costs of transportation, user charges & regular meals

20. RECOMMENDATIONS For ART patients identified as living in poverty /food insecurity : • Scale-up of Food Assistance programme at health facilities through World Food Programme (WFP) - progressing • Cancellation of user charges • Financial Assistance for transportation costs • Inclusion of ART in the National Health Insurance Scheme (NHIS)

21. Thank you for your time ... For further info. on HIV & AIDS epidemic, research and programmes in Ghana visit –> www.ghanaids.gov.gh