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Résumé
Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study
Norma C. Ware1*, John Idoko2, Sylvia Kaaya3, Irene Andia Biraro4, Monique A.
Wyatt1, Oche Agbaji2, Guerino Chalamilla5,6, David R. Bangsberg1,7,8
1 Harvard Medical School, Boston, Massachusetts, United States of America, 2
Jos University, Jos, Nigeria, 3 Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania, 4 Mbarara University of Science and
Technology, Mbarara, Uganda, 5 Muhimbili University/Dar es Salaam City
Council/Harvard School of Public Health HIV/AIDS Care and Treatment Program,
Dar es Salaam, Tanzania, 6 Harvard School of Public Health, Boston,
Massachusetts, United States of America, 7 Massachusetts General Hospital,
Boston, Massachusetts, United States of America, 8 Harvard Initiative for
Global Health, Cambridge, Massachusetts, United States of America
Background
Individuals living with HIV/AIDS in sub-Saharan Africa generally take more
than 90% of prescribed doses of antiretroviral therapy (ART). This number
exceeds the levels of adherence observed in North America and dispels early
scale-up concerns that adherence would be inadequate in settings of extreme
poverty. This paper offers an explanation and theoretical model of ART
adherence success based on the results of an ethnographic study in three
sub-Saharan African countries.
Methods and Findings
Determinants of ART adherence for HIV-infected persons in sub-Saharan Africa
were examined with ethnographic research methods. 414 in-person interviews
were carried out with 252 persons taking ART, their treatment partners, and
health care professionals at HIV treatment sites in Jos, Nigeria; Dar es
Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic
activities were also conducted. Data were examined using category
construction and interpretive approaches to analysis. Findings indicate that
individuals taking ART routinely overcome economic obstacles to ART
adherence through a number of deliberate strategies aimed at prioritizing
adherence: borrowing and begging transport funds, making impossible
choices to allocate resources in favor of treatment, and doing without.
Prioritization of adherence is accomplished through resources and help made
available by treatment partners, other family members and friends, and
health care providers. Helpers expect adherence and make their expectations
known, creating a responsibility on the part of patients to adhere. Patients
adhere to promote good will on the part of helpers, thereby ensuring help
will be available when future needs arise.
Conclusion
Adherence success in sub-Saharan Africa can be explained as a means of
fulfilling social responsibilities and thus preserving social capital in
essential relationships.
Funding: This study was supported by grants from the U.S. National Institute
of Mental Health (NIMH, R21 MH077539, MH54907) and the Harvard University
Program on AIDS. DRB was funded by a grant from the National Institute of
Alcohol and Alcoholism (K-24 AA 015287) and the NIMH (MH54907). The funders
played no role in the design or conduct of the research, the decision to
publish, or the preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests
exist.
Academic Editor: Chris Beyrer, Johns Hopkins University, United States of
America
Citation: Ware NC, Idoko J, Kaaya S, Biraro IA, Wyatt MA, et al. (2009)
Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study.
PLoS Med 6(1): e1000011 doi:10.1371/journal.pmed.1000011
Received: June 3, 2008; Accepted: November 19, 2008; Published: January 27,
2009
Copyright: © 2009 Ware et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Abbreviations: ART, antiretroviral therapy
* To whom correspondence should be addressed. E-mail:
norma_ware@hms.harvard.edu