title: Factors influencing adherence to antiretroviral treatment in Nepal: a mixed-methods study.
abstract: BACKGROUND
  Antiretroviral therapy (ART) is a lifesaver for individual patients treated for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Maintaining optimal adherence to antiretroviral drugs is essential for HIV infection management. This study aimed to understand the factors influencing adherence amongst ART-prescribed patients and care providers in Nepal.
  
  
  METHODS
  A cross-sectional mixed-methods study surveying 330 ART-prescribed patients and 34 in-depth interviews with three different types of stakeholders: patients, care providers, and key people at policy level. Adherence was assessed through survey self-reporting and during the interviews. A multivariate logistic regression model was used to identify factors associated with adherence, supplemented with a thematic analysis of the interview transcripts.
  
  
  RESULTS
  A total of 282 (85.5%) respondents reported complete adherence, i.e. no missed doses in the four-weeks prior to interview. Major factors influencing adherence were: non-disclosure of HIV status (OR = 17.99, p = 0.014); alcohol use (OR = 12.89, p = <0.001), being female (OR = 6.91, p = 0.001), being illiterate (OR = 4.58, p = 0.015), side-effects (OR = 6.04, p = 0.025), ART started ≤24 months (OR = 3.18, p = 0.009), travel time to hospital >1 hour (OR = 2.84, p = 0.035). Similarly, lack of knowledge and negative perception towards ART medications also significantly affected non-adherence. Transport costs (for repeat prescription), followed by pills running out, not wanting others to notice, side-effects, and being busy were the most common reasons for non-adherence. The interviews also revealed religious or ritual obstacles, stigma and discrimination, ART-associated costs, transport problems, lack of support, and side-effects as contributing to non-adherence.
  
  
  CONCLUSIONS
  Improving adherence requires a supportive environment; accessible treatment; clear instructions about regimens; and regimens tailored to individual patients' lifestyles. Healthcare workers should address some of the practical and cultural issues around ART medicine whilst policy-makers should develop appropriate social policy to promote adherence among ART-prescribed patients.
authors.affiliation: School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom. s.wasti@sheffield.ac.uk
authors.forename: Sharada P
authors.initials: SP
authors.lastname: Wasti
authors.forename: Padam
authors.initials: P
authors.lastname: Simkhada
authors.forename: Julian
authors.initials: J
authors.lastname: Randall
authors.forename: Jennifer V
authors.initials: JV
authors.lastname: Freeman
authors.forename: Edwin
authors.initials: E
authors.lastname: van Teijlingen
mesh_terms: D000293:Adolescent; D000328:Adult; D000428:Alcohol Drinking; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D004522:Educational Status; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009390:Nepal; D012737:Sex Factors; D012923:Social Class; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D044966:Anti-Retroviral Agents