Levels of near-perfect adherence to life saving antiretroviral drugs among African HIV patients should be understood as a means of preserving key social relationships, says a new study.
In Sub-Saharan Africa, adherence to these anti-HIV drugs improves patients' health, which is also a strong predictor of adherence success in developed countries. But for individuals living in extreme poverty, adhering to antiretroviral medicine regimens also helps them protect the relationships they rely upon to survive.
Norma Ware from Harvard University, Boston, USA and colleagues interviewed 252 patients and caregivers in Nigeria, Tanzania and Uganda, and identified several strategies used by patients to overcome economic obstacles to ART adherence. Strategies aimed at prioritizing adherence included borrowing and begging for funds to pay for travel to clinics, making difficult choices that reallocated available resources in favor of treatment, and "doing without."
Dr. Ware and colleagues report that individuals' prioritizing of ART adherence reflected the importance of relationships as a resource for managing economic hardship: caregivers and supporters expected patients to adhere to ART, and they made their expectations known. This created a responsibility among patients to adhere. Patients, in turn, adhered to their treatment to promote good will from their caregivers, thereby ensuring help will be available when future needs arise, say the authors.
That HIV patients in Africa achieve close to 90% adherence rates—far exceeding those achieved in North America—is remarkable given the "formidable obstacles in the poorest regions of the world," say the authors. This "dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty." The authors conclude that adherence success is best explained as a means of fulfilling social responsibilities and thus preserving social capital in economic and cultural settings where good relationships are necessary for survival.
In an expert commentary on the study, Agnes Binagwaho and Niloo Ratnayake, who were not involved in the study, discuss the importance of social capital in African societies compared to more developed countries, stating that "people in the US tend to be more individualistic and therefore less focused upon and connected to the group as a whole." The challenge for African will be to "maintain social capital while improving economic development, which can bring a more individualistic way of life."
- Ware et al. Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study. PLoS Medicine, 2009; 6 (1): e11 DOI: 10.1371/journal.pmed.1000011
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