Background: The advent of highly active antiretroviral therapy (HAART) ushered in a new era in the management of the AIDS pandemic with new drugs, new strategies, new vigour from treating clinicians and enthusiasm on the part of their patients. What soon became evident, however, was the vital importance of patient adherence to prescribed medication in order to obtain full therapeutic benefits. Several factors can influence adherence to HIV drug regimens. Many treatment regimes are complex, requiring patients to take a number of drugs at set times during the day, some on a full stomach and others on an empty one. Other factors that could contribute to non-adherence include: forgetting to take medications, cost factor, side effects, incorrect use of drug, social reasons, denial or poor knowledge of drug regime. If the correct regimen is not prescribed and if patients do not adhere to therapy, then the possibility of resistant strains is high. Improving adherence is therefore arguably the single most important means of optimising overall therapeutic outcomes. Although several studies regarding patient adherence have been performed in the public health care sector, data on adherence in patients from the private health care sector of South Africa remain limited. Many factors influence compliance and identifying these factors may assist in the design of strategies to enhance adherence to such demanding regimens. This study aimed to identify these factors among private sector patients.Method: Descriptive cross-sectional study was conducted among all consenting patients with HIV who visited the rooms of participating private sector doctors from May to July 2005. A questionnaire was administered to consenting participants. Participants who reported missing any medication on any day were considered non-adherent. The data obtained was analysed using SPSS 11.5. A probability value of 5% or less was regarded as being statistically significant. Categorical data was described using frequency tables and bar charts. Pearson’s chi-square tests or Fischer’s exact tests were used interchangeably as appropriate to assess associations between categorical variables. The study received ethics approval from the University of KwaZulu-Natal’s Nelson R Mandela School of Medicine Ethics Committee.Results: A total of 55 patients completed the questionnaires and 10 patients refused to participate. There was no statistical difference between adherence to treatment and demographics such as age, gender and marital status. In this study 89.1% of patients were classified as non-adherent and reasons for nonadherence included difficulty in swallowing medicines (67.3%) (p = 0.01); side effects (61.8%) (p = 0.03); forgetting to take medication (58.2%) (p = 0.003); and not wanting to reveal their HIV status (41.8%) (p = 0.03). Common side effects experienced were nausea, dizziness, insomnia, tiredness or weakness. Reasons for taking their medicines included tablets would save their lives (83.6%); understand how to take the medication (81.8%); tablets would help them feel better (80.0%); and were educated about their illness (78.2%). The majority of participants (65.5%) were on two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI). All participants that were on a regimen that comprised protease inhibitors and two NRTIs were found to be non-adherent.Conclusion: Some barriers to adherence among this cohort of private sector patients are similar to those experienced by public sector patients. It will be important for doctors to identify these problems and implement strategies that could improve adherence, e.g. using short message services (SMSs) reminders for those patients prone to forgetting to take their medicines, breaking the tablets into smaller pieces in order to overcome the difficulty of swallowing, if the medication is not available in a liquid form, looking at alternative medication with lesser or more tolerant side effect profiles and greater counselling on the drugs.
Supply-Side and Demand-Side Cost Sharing in Health Care