Background: The widespread availability of antiretroviral therapy has led to a reduction
in mortality and morbidity in HIV/AIDS patients in Botswana. However, high levels of
adherence to antiretroviral drugs are necessary for good virologic and immunologic
responses which are critical for improved survival. Approximately 100 women who
initiated highly active antiretroviral therapy (HAART) while pregnant are currently being
followed in 4 research clinics in Botswana. There is currently no data available on
adherence among women initiating HAART during pregnancy at these clinics or among
pregnant women on HAART elsewhere in Botswana. It is critical to study and understand
the key factors that influence adherence among women receiving treatment at these
clinics following initiation during pregnancy, to avert or reduce the consequences of
treatment failure.
Aim: The study aimed to assess the level of adherence and to identify the barriers to
adherence and the motivations for good adherence to antiretroviral therapy, amongst
women who commenced treatment while pregnant at research clinics in Molepolole,
Mochudi, Lobatse and Gaborone.
Study Population and Sample: All women who initiated HAART during pregnancy and
were currently receiving treatment at the research clinics in Molepolole, Lobatse,
Gaborone and Mochudi in Botswana.
Method: A quantitative study was conducted using a cross sectional descriptive design.
Data was collected using a structured questionnaire administered to all women receiving
standard care HAART at the clinics, during their monthly refill visits between 02
September and 15th October, 2009. Additional relevant information was extracted from
participant’s medical records using a data extraction tool. Informed consent was obtained
from the women who participated in the study prior to administration of the questionnaire
and subsequent data extraction from their medical records. Data was analysed with SPSS
version 14 using descriptive and analytic statistics. Adherence was categorized as
excellent (100%), adequate (≥95%) and inadequate (<95%).
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Results: A total of 94 women consented to the study and were interviewed across the 4
sites. The mean CD4 counts at antenatal, immediate post natal and late post natal were
266, 315 and 346 respectively. Overall adherence of the study participants was good,
99% had adequate adherence and 67% of the women had excellent adherence using pill
count over a six month period. Self reported adherence was 100% for 1-day, 3-day and 7-
day recall. Ninety-nine percent (99%) of the subjects received adherence counselling
before initiating therapy while approximately 33% of the women received counselling at
every visit. Ninety percent (90%) of the women rated the quality of services received at
the clinic as very good. Reasons cited for ever missing medications were forgetfulness
(18%) and not having medications at the time of the dose (13%). The participants had
high knowledge of ARVs and HIV/AIDS. There was no significant difference in
adherence during pregnancy, immediately post partum and the late post partum period.
There was no significant association between adherence and demographic factors,
socioeconomic factors, quality and adequacy of service provision as well as knowledge
attitudes and perceptions towards HIV/AIDS and ARVs. Bivariate analysis showed no
association in this study between the factors usually known to be associated with
adherence from other studies.
Conclusions: A high level of adherence was observed among the study population, with
99% achieving adequate adherence of ≥ 95% and 67% maintaining excellent adherence
of 100% during the period reviewed, however these might be overestimates of actual
adherence. Even if there is a degree of over-estimation the study still shows a high level
of adherence among participants in a research cohort who received a higher standard of
care with consistent and adequate adherence monitoring throughout their duration of care.
Recommendations: Although the study reported a high level of adherence, there is need
to devise mechanisms of making the medications portable and strengthening mechanisms
for reminding patients about timing of the doses. As Botswana rolls out universal access
to HAART among pregnant women in the country, it will be essential to learn from this
cohort experience so as to attain excellent adherence levels within the general population.