Discussion
This study explored HIV patients’ facilitators and barriers to ART
compliance in addition to their views, perceptions and needs of patient
care provided to them. The thematic analysis results identified key
barriers for HIV patients’ compliance and suggest inappropriate
patient-care and discrimination against HIV patients in Jordan.
Two major themes related to patients’ compliance to ART have emerged
from the obtained data: patient-related, and medication-related. Each
theme branches to sub-themes, either facilitate or obstruct the
medication adherence. Patient-related factor that contains sub-themes
such as psychological reactions, family and friends support, and
reminders. In which, stigmatization, fear, happiness, strong beliefs and
self-confidence are the main factor identified among psychological
reactions sub-theme. Stigmatization creates a great challenge for HIV
patient, arise from the perception that HIV persons are scared to be
asked about ART medications or they fear if someone has knowledge about
these therapies. This was agreed by many different studies, where
patients fear to take the bill in
front of other people such as their work colleague to avoid being
expelled from their
job20,21.
People living with a high level of stigma are 3.3 times more likely to
be non-adherent to ART therapy than from people with a low level of
stigma22. Whilst
stigmatization was frequently mentioned as a complex phenomenon to
decrease medication adherence, happiness, strong beliefs and
self-confidence were reported as facilitators for adherence.
Surprisingly happiness, which was mentioned by a few participants is
that the infection making them more caring for their health status.
Moreover, being one of the infected persons gives him/ her the chance to
help other HIV persons.
As been observed from this study having family and friend support adds
on to patient satisfaction and can invoke participant adherence. The
participants highlight the importance of the friend’s support since its
difficult most of the time to tell the family about their infection.
Having support from their friends helped them to rise again and being
stronger; which is illustrated in other
literature23,24.
Apart from family and friend support, reminders are identified as an
important facilitator for adherence. Having the advantage from
associating ART therapy with a repeated habit such as lunch or putting
the drugs on a place where is always checked for assuring the drug had
been taken enhance their adherence; which in fact generally consistent
with the findings of Bezabhe et al. a qualitative study conducted
in Ethiopia on twenty-four patients, where the use of electronic devices
such as mobile phone and alarms, helped AIDS patients to take their
drugs without the need of others reminding
13.
Medication-related factors were found to have a contrasting effect on
adherence. Regarding the side effects; suffering from a number of side
effects such as vomiting, diarrhea, vertigo, fat deposition,
hallucinations, insomnia, and drowsiness negatively affects patients’
medication adherence. This was in line with a previous study where 27%
of AIDS patients afraid from the side effects of the
drugs25. Also, another
study recruited 3414 antiretroviral-naive HAART patients revealed that
628 patients (18.4%) have discontinued their regimen because of drug
toxicity26.
Living a long healthy life, away from relapses of the health status or
suffering from other diseases that may occur because deterioration in
the immunity, was a critical factor that encourages the patient to keep
on with ART therapy. The patients noticed that their CD4 cell count and
viral load improved after taking their therapy and most of the patient
body weight relatively increased. All these improvements motivate the
patients to continue their therapy. This was also found in previous
studies27,28.
Finally, participants complained about the number of bills that were
taken, the continuity on therapy for long life and taking the drug
daily, the pharmaceutical form of the drug and the need for special
storage conditions for certain forms such as the jell. All of which make
the patients feel disturbed. In fact unfortunately not mentioned or
highlighted in the literature previously.
Notably, no study was conducted to assess awareness and knowledge
regarding pharmaceutical care among such population in Jordan.
Consequently, this study was implemented to better understand the type
of pharmaceutical services HIV patients received. Sadly, the vast
majority of the participants said that they didn’t have a pharmacist in
their healthcare team, while in fact there is a pharmacist in their
healthcare teams. Unfortunately, according to the participants the only
services the pharmacist provides are just dispensing medication and the
vast majority didn’t know what the pharmacist roles are. All of the
participants agreed that there are insufficient pharmaceutical services
provided, with little or even sometimes no respect for those patients,
which is actually contrasts the ultimate goal of the application of
pharmaceutical care 29.
The present study illustrated that when the participants were asked “Do
you need an experienced pharmacist and expert medication to follow your
treatment, medications, and doses?” the participants demonstrated a
positive attitude and overall agreement which was observed when they
were provided a suggestion about the presence of the specialist
pharmacist in HIV. According to the participants, the presence of a
specialist pharmacist in their health care team and the implementation
of pharmaceutical care may positively influence the adherence of the
patients to their treatment. This was consistent with other studies
which concluded that applying pharmaceutical care services shown
positive outcomes with improving medication use, adherence, and
surrogate outcome30-32.
Pharmaceutical care services were found to give the pharmacists the
opportunity to improve HIV patients adherence rate and to enhance
treatment response with higher CD4 percentage
32.
Among the strengths of this study, is that it was the first study
comprehensively examine the effect of several factors that affect ART
therapy adherence among HIV Jordanian patients. However, there are some
methodological limitations. One of the limitations of this study was the
fact that most of the HIV/AIDS patients were unwilling to take part in
the interviews due to fear of their disease being revealed and its
consequences like stigma and being boycotted due to the country’s
cultural attitudes, whilst when the participants were assured that their
data would be kept confidential in all stages of this research and that
they were free to withdraw from the interviews whenever they decided not
to continue, this limitation was resolved to some extent. Moreover, we
were challenged with a small sample size, firstly this is a qualitative
study and it is known that usually, a small sample is recruited,
secondly, our tradition and fear from disclosure decrease the
participant’s motivation to be one of the volunteers.