Date Published: January 27, 2009
Publisher: Public Library of Science
Author(s): Agnes Binagwaho, Niloo Ratnayake
Abstract: Agnes Binagwaho and Niloo Ratnayake discuss the implications of a new ethnographic study that explores the reasons for the high rates of adherence to antiretroviral medicines in Africa.
Partial Text: In the late 1990s and early 21st century, some public health officials in the Western world believed that Africans would never be compliant with antiretroviral therapy (ART) because the continent’s uneducated, illiterate population was driven by day-to-day concerns without much thought for the long-term future. On top of this, many claimed that ART was a luxury for Africans and that the complex disease would be too difficult for African doctors to manage in the middle of nowhere with no water or electricity. Some went so far as to insist that giving ART to a likely noncompliant population would create drug resistance and were willing to sacrifice Africa for the good of global public health .
Ware and colleagues asked patients, treatment partners (those who assisted patients in their efforts to take antiretroviral medications), and health care providers what the driving factors were behind adherence in three sites: (1) The Immune Suppression Syndrome clinic at Mbarara University of Science and Technology in Mbarara, Uganda; (2) the ART clinic of Amana District Hospital in Dar es Salaam, Tanzania; and (3) the HIV/AIDS clinic at Jos University Teaching Hospital in Jos, Nigeria. Patient interviews focused on experiences with taking ART, clinic visits, and help from treatment partners. Treatment partner interviews targeted the types of help that they give, feelings about being a treatment partner, and opinions on their impact. Health care workers, such as clinicians, nurses, and others, were asked to describe typical clinic visits, ways adherence is discussed at these visits, and views of patient obstacles towards adherence. The researchers also conducted observations of clinic visits, with a focus on observing routine follow-up visits of patients taking ART, counseling sessions, health education sessions, and the dispensing of antiretroviral medications. In all, 158 patients, 45 treatment partners, and 49 health care workers were interviewed. There were 414 interviews and 136 observation sessions conducted across the three sites.
Ware and colleagues’ multi-country, multi-setting study used a methodology of interpersonal interaction that allowed people to talk simply to the researchers, without complicated study designs getting in the way. Instead of coming with experts and boxes to check, the researchers captured the viewpoint of the patient, treatment partner, and grassroots-level health care worker. The findings show the importance of social capital (the connections between people) and reveal that social responsibility in Africa pushes people to be “good” (adherent) patients. Social capital has been used in other countries such as Rwanda, where those who want treatment must come to the clinic with a relative or members of their association.
Having clearly established the importance of social capital in promoting adherence to ART, future studies should focus both on its protective effects outside of the scope of HIV/AIDS and on how to maintain social capital while improving economic development, which can bring a more individualistic way of life. A developed economy provides an environment that allows the growth of individualism, while the poor tend to depend on their community for survival. Social capital can be a useful tool in promoting adherence to medications in patients with chronic diseases, who are at higher risk of depression than the general population . As countries in Africa become more economically developed, it will be increasingly more important for them to actively find tools to maintain their social capital.