title: Understanding Antiretroviral Treatment Adherence Among HIV-Positive Women at Four Postpartum Time Intervals: Qualitative Results from the Kabeho Study in Rwanda.
abstract: As lifelong antiretroviral therapy (ART) for pregnant women is implemented, it is important to understand the attitudes and norms affecting women's postpartum ART adherence. This is a qualitative cross-sectional study of HIV-positive postpartum women (n = 112) enrolled in a 2-year observational prospective cohort in Rwanda. Informed by the Theory of Reasoned Action (TRA), we conducted in-depth interviews with women whose children were 0-6, 7-12, 13-18, or 21-24 months of age to describe factors contributing to adherence and changes over time. Positive ART attitudes reported by women included mothers' health promotion, prevention of infant HIV infection, higher CD4 count, and improved physical appearance. Negative attitudes were few, but included side effects and the lifelong nature of treatment. Learning from people living with HIV (PLHIV) was identified as a norm facilitating adherence; ART adherence was inhibited by fear of disclosure or stigmatization in communities and clinics. Poor adherence behaviors were common immediately after HIV diagnosis, not necessarily during prevention of mother-to-child transmission (PMTCT). Women with older children, most of whom stopped breastfeeding by 13-18 months, reported more barriers and missed doses than women with younger children. The TRA was useful in identifying the collective influence of attitudes, norms, and intentions on behavior. Findings suggest that HIV-positive women are vulnerable to poor adherence following HIV diagnosis and around the time of breastfeeding cessation. Lifelong treatment adherence can be supported through PLHIV exemplifying long-term ART use, fewer and less stigmatizing clinic visits, and counseling messages highlighting the benefits of drugs on appearance and illness prevention and incorporating biological feedback.
authors.affiliation: 1 Elizabeth Glaser Pediatric AIDS Foundation , Washington, District of Columbia.
authors.forename: Michelle M
authors.initials: MM
authors.lastname: Gill
authors.affiliation: 2 Elizabeth Glaser Pediatric AIDS Foundation , Kigali, Rwanda .
authors.forename: Aline
authors.initials: A
authors.lastname: Umutoni
authors.affiliation: 3 Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University , Washington, District of Columbia.
authors.forename: Heather J
authors.initials: HJ
authors.lastname: Hoffman
authors.affiliation: 2 Elizabeth Glaser Pediatric AIDS Foundation , Kigali, Rwanda .
authors.forename: Dieudonne
authors.initials: D
authors.lastname: Ndatimana
authors.affiliation: 2 Elizabeth Glaser Pediatric AIDS Foundation , Kigali, Rwanda .
authors.forename: Gilles F
authors.initials: GF
authors.lastname: Ndayisaba
authors.affiliation: 2 Elizabeth Glaser Pediatric AIDS Foundation , Kigali, Rwanda .
authors.forename: Solange
authors.initials: S
authors.lastname: Kibitenga
authors.affiliation: 4 Rwanda Biomedical Center/Ministry of Health , Kigali, Rwanda .
authors.forename: Placidie
authors.initials: P
authors.lastname: Mugwaneza
authors.affiliation: 5 Rwanda University Teaching Hospitals (CHU) , Kigali, Rwanda .
authors.forename: Anita
authors.initials: A
authors.lastname: Asiimwe
authors.affiliation: 6 MEASURE Evaluation, University of North Carolina , Chapel Hill, North Carolina.
authors.forename: Emily A
authors.initials: EA
authors.lastname: Bobrow
mesh_terms: D000328:Adult; D001942:Breast Feeding; D018791:CD4 Lymphocyte Count; D003430:Cross-Sectional Studies; D005239:Fear; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000208:ethnology / Q000523:psychology; D006801:Humans; D007223:Infant; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D007407:Interviews as Topic; D055118:Medication Adherence; D049590:Postpartum Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000208:ethnology / Q000523:psychology; D037841:Pregnant People / Q000523:psychology*; D011446:Prospective Studies; D036301:Qualitative Research; D012432:Rwanda / Q000453:epidemiology; D057545:Social Stigma
keywords: Option B+; PMTCT; Rwanda; adherence; lifelong antiretroviral therapy (ART)