title: What makes orphans in Kigali, Rwanda, non-adherent to antiretroviral therapy? Perspectives of their caregivers.
abstract: BACKGROUND
  Every year, approximately 260,000 children are infected with HIV in low- and middle-income countries. The timely initiation and high level of maintenance of antiretroviral therapy (ART) are crucial to reducing the suffering of HIV-positive children. We need to develop a better understanding of the background of children's ART non-adherence because it is not well understood. The purpose of this study is to explore the background related to ART non-adherence, specifically in relation to the orphan status of children in Kigali, Rwanda.
  
  
  METHODS
  We conducted 19 focus group discussions with a total of 121 caregivers of HIV-positive children in Kigali. The primary data for analysis were verbatim transcripts and socio-demographic data. A content analysis was performed for qualitative data analysis and interpretation.
  
  
  RESULTS
  The study found several contextual factors that influenced non-adherence: among double orphans, there was psychological distance between the caregivers and children, whereas economic burden was the primary issue among paternal orphans. The factors promoting adherence also were unique to each orphan status, such as the positive attitude about disclosing serostatus to the child by double orphans' caregivers, and feelings of guilt about the child's condition among non-orphaned caregivers.
  
  
  CONCLUSIONS
  Knowledge of orphan status is essential to elucidate the factors influencing ART adherence among HIV-positive children. In this qualitative study, we identified the orphan-related contextual factors that influenced ART adherence. Understanding the social context is important in dealing with the challenges to ART adherence among HIV-positive children.
authors.affiliation: Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
authors.forename: Kimiyo
authors.initials: K
authors.lastname: Kikuchi
authors.affiliation: Department of Public Health, School of Public Health and Health Sciences, University of Massachusetts-Amherst, Amherst, MA, USA.
authors.forename: Krishna C
authors.initials: KC
authors.lastname: Poudel
authors.affiliation: Division of Obstetrics and Gynecology, King Faisal Hospital, Kigali, Rwanda.
authors.forename: John
authors.initials: J
authors.lastname: Muganda
authors.affiliation: Department of Psychology, Meiji Gakuin University, Tokyo, Japan.
authors.forename: Tomoko
authors.initials: T
authors.lastname: Sato
authors.affiliation: Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Vincent
authors.initials: V
authors.lastname: Mutabazi
authors.affiliation: Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Ribakare
authors.initials: R
authors.lastname: Muhayimpundu
authors.affiliation: Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Adolphe
authors.initials: A
authors.lastname: Majyambere
authors.affiliation: Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Simon P
authors.initials: SP
authors.lastname: Nyonsenga
authors.affiliation: Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
authors.forename: Eriko
authors.initials: E
authors.lastname: Sase
authors.affiliation: Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; mjimba@m.u-tokyo.ac.jp.
authors.forename: Masamine
authors.initials: M
authors.lastname: Jimba
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D017028:Caregivers; D002648:Child; D054540:Child, Orphaned; D002675:Child, Preschool; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007223:Infant; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D012432:Rwanda; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents
keywords: AIDS; ART adherence; HIV; Rwanda; antiretroviral therapy; child; orphan; sub-Saharan Africa