Background to the Study
The twenty first century has witnessed the global health problem of Human Immune Virus and Acquired Immune Deficiency Syndrome (HIV & AIDS), that has produced the greatest challenge to mankind. The epidemic is a global crisis an unprecedented threat and formidable challenge to human development and social process.
Human immune virus is a precursor of acquired immune deficiency syndrome. This term was introduced by the Center for Disease Control and Prevention (CDCP) in 1982 to describe the syndrome. Three main transmission routes identified for HIV were: 1) sexual route, 2) blood or blood product route and 3) mother to child transmission. The status of any individual suspected of having HIV is ascertained through a HIV antibody test known as ELISA test or Polymerase Chain Reaction (PCR) test, both are effective and reliable (Soul City 2004 as in Kgomotso, 2009). Over the years HIV & AIDs have progressed to be one of the biggest killers, especially in sub-Saharan Africa where AIDs is the leading cause of death without limitations in terms of socio-demographic variables like age sex education, gender, marital status etc. People living positive with HIV were formerly regarded as PLWHA (People living with HIV & AIDs), recently the nomenclature changed to PLP (People living Positive) (UNAIDS/WHO 2007, as in Kgomotso, 2009).
The syndrome was first diagnosed globally in 1981 (Joint United Nations programmes 2006, as in Kgomotso, 2009) while in Nigeria it was diagnosed in a 13 year old girl in 1986 and has since then become one of the most destructive pandemics in recorded history (Idoko, Agbaji Pam, Taylor, Samson & Moses, 2005).
Anambra State was recently recorded as one of the “HIV hotspot” states with high prevalence rate of HIV infection (Peterson & Obileye, 2002 & Fatunmole, 2012). Anambra being one of the biggest commercial cities in Nigeria has a very big drug market and recent study have unveiled that a lot of substandard drugs manufactured both locally and abroad were in circulation in the state and country and this have links to high ARV and other drugs resistance and adverse effects (Peterson & Obileye, 2002).
Since after the first reported case in Nigeria in 1986 the Federal Government adopted a multi-sector approach to preventing the HIV & AIDs panademic. In 1991 the Federal Ministry of Health as the Nations health institution provided a leading role in HIV & AIDs prevention by initiating behavioural intervention and also assessing the impact of AIDs panademic in Nigeria through an institutionalized and sustained HIV surveillance system.
In the same year, the Federal Ministry of Health developed a comprehensive antiretroviral drug treatment programme for people living positive as part of the care and support efforts. The Presidential Committee on AIDs (PCA) and the National Action Committee on AIDs (NACA) were established in the year 2000 and they facilitated a co-ordinated multi sector response through provision of comprehensive prevention and care services within the context of HIV & AIDs Emergency Action. Plan (HEAP), HIV & AIDs Health Sector Plan, and National Strategic Framework (NSF). The Ministry further explained that 36 federated states of the country has a State Action Committee on AIDs whose responsibility are to ensure prevention, reduction and control of HIV & AIDs clients in their communities. In Anambra State, Anambra State Action Committee on AIDs (ANSACA) is the institutional body that is deeply involved in conducting AIDs prevention related training, assertive skill training, AIDs awareness and instrumental knowledge acquisition learning to clients as well as give medical treatment (ARV drugs) and care services to people living positive (PLP). It is equally apparent that ANSACA along with UN agency and Community based NGOs in the state such as Pro Gender Health International has been carrying out a variety of HIV & AIDs prevention related activities (ANSACA, 2009).
Since the notification of HIV & AIDs in Nigeria, the country has been experiencing a “generalised” epidemic with the state’s HIV prevalence persistently above one percent in pregnant women attending antenatal clinic since 1999 (Federal Ministry of Health, 2007). Furthermore, the prevalence of HIV infection among antenatal clinic clients was 1.8 per cent in 1991, 4.5 per cent in 1996, 5.8 per cent in 2001, 5.0 per cent in 2003 and 4.4, per cent in 2005. The obvious implication is that in 2003, it was estimated that about 3.8 million persons were living positive in the country while 4.5 million were living positive in 2005 (FMOH 2005). In addition the life expectancy of the nation which increased from 45 years in 1963 to 51 years in 1991 as a result of improved standard of living and quality healthcare services dropped drastically to 43.4 years by 2003 (UNDP/HDR, 2003).
Major epidemic of HIV & AIDS infection is presently occurring in Nigeria generally, and Anambra State in particular (FMOH 2003, 2005). The epidemiological feature of HIV infection in Anambra State is strikingly distinct from those in other states of the federation as unprotected sexual intercourse and heterosexual activities are the major mode of transmission. Similarly the 2003 HIV sero-prevalence in Anambra State indicated that the state population of 3,964, 073 people, 107,853 people were living with HIV & AIDs. However 15,130 were youths, aged 15 to 24 years were infected with HIV & AIDS as at 2003 and this number has increased to 20,136 by 2008. In addition, the number of deaths due to HIV & AIDs was 11,049 in 2003, and had increased to 11,120 by 2008, whereas cumulative number of death due to AIDS were 81,905 in 2003 and had increased to 139,306 by 2008. Also the number of orphans in the state in 2003 was 58,548 and had increased to 88,569 by 2008 respectively (FMOH 2003, 2005). The high morbidity and mortality rate of the infection was a big challenge to both the State and Federal Government of Nigeria, hence the initiation of antiretroviral drugs to increase the life expectancy rate of the people living positive in Anambra state and other states of the federation.
Antiretroviral drugs (ARV) are medications used in reducing the ability of Human Immune Virus (HIV) to replicate itself in human body system, and increase the ability of the body to fight infection and decrease the symptoms experienced by a person infected with HIV (Calles, 2003). Antiretroviral drugs according to GHAIN (2006) are meant for treatment of HIV and not a cure, such drugs equally prevent the onset of AIDS if taken at regular intervals for the rest of the person’s life. The primary goal of these drugs is to reduce the ability of HIV virus to reproduce itself, thereby allowing the repair of the immune system damage associated with HIV infection.
In the developed would PLPs are exposed to as many as 250 possible combination of “cocktails” of ARV drugs with AZT or similar drugs as HAART. Doctor’s before prescription takes the patient through a lot of test to determine which drug is best suitable for the patient and when it is best for the patient to start treatment. The reverse is the case with Nigeria since PLP are exposed to just very few drugs and most of the designated hospitals do not have the instrument for testing the patients cluster of differentiation 4 (CD4) counts before commencing treatment (Chesney, 2000, Stanic & Schneider, 2005) as in Kgomtso, 2009).
Moreover, drug distribution in Nigeria is very “Choatic”. Drugs can be purchased from nearly any outlet, including manufactures, wholesalers and retailers. Both over-the-counter and controlled drugs are available in open markets, pharmacies, patent vendors and hospitals. In other words, drugs that are available are very easy to find and very difficult to control. However, many available drugs, especially from illegal outlets are fake and/or substandard. Therefore, the end user may have trouble accessing drug quality, at the right price in the right quantity or quality and from the right people (Anyika, 1999).
Recent discovery made by scientists in the United States of America school of medicine and college of medicine, Ibadan revealed that bee venom is a more powerful and potent ARV drug than the ones already in use. The mode of action of ARV drugs inhibits the virus’s ability to replicate but this anti replication factor does nothing to stop the initial infection, while the bee venom toxin called melittin attacks an essential part of the virus’ structure. The melittin according to scientists form little pore-like attack complexes and ruptures the envelope, stripping it off the virus, in other wards an inherent physical property of HIV is attacked and there isn’t any way for the virus to adapt to that (Orakpo, 2013).
The major classes of these drugs according to FMOH (2005) are Nucleoside Reverse Transcriptase inhibitors or Nucleoside analogue reverse transcriptase inhibitors (NRTIS, Non- nucleoside Reverse Transcriptase inhibitors (NNRTIs), Portease Inhibitors (PIS) Fusion inhibitors (FI) and Integrease inhibitors. The drugs in each of the classes interfere with specific steps in the HIV replication cycle. ARVs or HAART entail a cocktail of drugs typically entailing at least one nucleoside analogue reverse transcriptase inhibitor (NRTI) such as emtricitabine (Emtrivia), and one non-nucleoside reverse transcriptase inhibitor (NNRTI). Both sets of drugs interfere with the reverse transcriptase enzyme, which is very crucial for the early stage reproduction of AIDS virus (Nattras, 2003).
Adherence to treatment with these drugs allow people living positive (PLP) to live normal life and be active in their fields of work by reducing the ability of HIV virus to replicate itself, thereby allowing repair of immune system damage associated with HIV infection. Most patients in Anambra State on ARV drugs in the 1990’s met with a lot of obstacles as majority of them could not afford to purchase the drugs because of the high cost. This makes the availability of the drugs to be on high demands, it was only the wealth minority were able to purchase and utilize the available drugs (UNAIDS 2008).
Availability is the ever accessibility and affordability of ARV drugs by PLP of all ages, sex, marital, status educational/qualifications and location at all times. As at 2002, the Nigerian government initiated an ambitious ARV treatment programme which aim to supply 10,000 adults and 5000 children with ARV drugs within one year. An initial 3.5million dollars worth of the drugs were imported at a subsidized monthly cost of seven dollars per person because most Nigerians then were living on less than 2 dollars per day (UNAIDS 2008). The programme was announced as “African’s largest ARV treatment programme”. By 2004 the programme had suffered a major set back as too many patients had to wait for up to three months for more drugs which could not only reverse the progress so far made by the already utilized drugs but could also increase the risk of HIV becoming resistant to antiretroviral (UNAIDs, 2008). The afore-mentioned situation was in contrast to the view of Hornby (1995) that availability is a thing or things that can be obtained and used at any point in time. Thesaurus (2002) equally viewed availability as a thing which has the quality of being at hand when needed that means, the drugs must be accessible, ever ready, handy and attainable. Availability has to do with quantity of ARV provided as well as the quantity that is accessible to the intended beneficiaries, it is a precursor of utilization.
UNFPA (2003) viewed utilization as relating to the number of people using a health facility or materials provided. However, Parks (2007) perceived utilization as a proportion of people in need of a health service who actually received the service in a given period. That means successful utilization is time bond. Peterson and Obileye (2002) viewed utilization from the perspective of gaining access to quality drugs for general healthcare and HIV related opportunistic infections (OIS) and not just gaining access to drugs. This study conceives utilization as the ability of PLP of all ages, sex, gender, marital status, educational qualifications and location come to the dispensing centers regularly to collect their ARV drugs and make appropriate use of them as demanded.
Utilization of antiretroviral drugs by PLP is determined by it’s availability at the designated hospitals in the state. The report by UNAIDS (2008) that the availability of antiretroviral drugs in the designated hospitals in the country suffered a major set back in 2004 is a pointer to the fact that utilization of the same service may have suffered set backs in Anambra State. The demands for antiretroviral drugs in Anambra state is on the high side as testified by FMOH (2003 & 2005) with 107,853 living positive with HIV in the State. About 11,049 died in 2003 and premonition is that, the death rate will be on the increase. ARV drugs as stated by Calles (2003) reduces the ability of HIV virus to replicate itself hence increase the ability of the body to fight infection if properly utilized. The increased death, rate of PLP in the state points to the fact that proper utilization of ARV drugs in the state is queried, hence the study to investigate the extent, PLP of various socio-demographic state utilize ARV drugs.
The socio-demographic variables influencing utilization of ARV drugs equally influences it’s availability since utilization is a precursor of availability. These demographic variables includes level of income, level of education, gender, age, occupation, marital status, urban-rural location amongst others. However Uzochukwu, Onwujekwe, Onoka, Okoli, Ugwu and Chukwuogo (2009) found out that in South-Eastern States of Nigeria, Anambra State inclusive the PLP who have formal education do not properly utilize the ARV drugs received, most defaulters in the designated hospitals in terms of improper collection and utilization of the ARV drugs were the educated PLPs. This results to low adherence to ARV drugs, this behaviour may be attributed to the fact that the educated PLPs have knowledge of the incurable state of the disease and the associated side effects thus, they stand to suffer as a result of consuming the drugs. Ezeokana, Nnedum, and Madu (2007) were equally of the view that people with little or no education have poor access to sex information in other words they are the worse victims of HIV and AIDS. This findings was in contrast to the discovery made by Sow, Coume, Gaye, Fall, Toure and Trace (2012) that there was no association between the educational status of PLPs in Senegal and their adherence to medications, but PLPs with at least a minimum of elementary education complied better to ARV medication than those with no formal education.
Collection of ARV drugs from the designated centers comes with some hidden costs, as a result of this, most PLP that are low income earners shy away from utilizing the services as at when due (JAAIDS, 2010). In Senegal too, occupation of PLPs had effect on their adherence to ARV drugs. Least level of adherence was among the unemployed PLPs due to the fact that they find it difficult to pay the sum of one thousand CFA being charged on monthly basis for replenishment of the ARV medication (Sow et al 2012).
Recent study have shown that male PLP were more adherent to ARV medication than the females (Sow et al 2012). The females shy away from treatment so that they will not be accused of immorality. In Anambra State, it is believed that HIV & AIDs is associated with “improper sex” and promiscuity and the fact that the society look up to women to uphold the moral integrity of the family and society at large (Public Health Watch, 2007).
People living positive in the urban areas are presumed to have more access to ARV medications than those in rural areas. This regional disparities in access to care often stem from weak healthcare systems and lack of human resources capacity outside of the cities. Technical capacities tend to be concentrated in the capital cities and major urban centers (Public Health Watch, 2007).
Sow et al (2012) unveiled that HIV & AIDS affect all ages in Senegal but the most vulnerable is the sexually active group (24-35years). This view was supported by Eleje, Ele, Okocha and Iloduba (2014), who confirmed that those affected by HIV in Nigeria fall within the age brackets of 20-24years and that they present late to the clinics for clinical care. The reason for this, includes poverty, stigmatization and ignorance. However Uzochukwu et al, (2009) revealed that older PLP appreciate their treatment more than the younger ones. In a study carried out on adherence of PLP to ARV drugs it was discovered that PLP who were 35 years of age and above adhere more to their therapy than the younger ones.
In Dakar, a higher adherence rate to ARV medications was noticed among the singles than the married PLPs, the reason being that the singles were looking up to the future with full expectation that complying with prescribed ARV will make them to have a normal life, get married and possibly have their own children (Sow et al, 2012). However, in Nigeria, the reverse was the case, adherence to ARV medication was higher with married people than singles. This was assumed to be as a result from pressure from loved ones, while the younger PLPs below the age of 35 years in most cases shy away from treatment as a result of poor encouragement from love ones, low income power and unemployment (Uzochukwu et al 2009).
These behaviours according to some theorist are expected in human existence. This study was buttressed by two theories and two models. These portray the psychological implications of certain behaviours seen in the PLP. The theories and models used include theory of help-seeking, theory of stages of illness and medical care, health belief model and choice making model.
Theory of help-seeking propounded by Mechanics (1978) described help-seeking behaviour during illness as being influenced by the individual or a person who makes decisions for the individual in other words autonomy or heteronomy decisions influence ARV drug utilization.
Theory of stages of illness and medical care propounded by Suchman (1965) outlined five stages of an individual’s decision process in determining whether or not to utilize healthcare services when ill. The stages of decision process includes: the individual’s symptoms experience, the individual assumption of a sick role, medical care contact, the assumption, of a dependent patient role via the acceptance of professional healthcare treatment and finally the individual’s recovery from illness. For a HIV positive person his recovery depends on his accepting his condition as being chronically ill and permanently on ARV drugs in order to live a relatively normal life.
Health belief model (HBM) propounded by Rosenstock, in the 1950s discussed the individual actions to treat and prevent diseases via consideration of four central variables which are the individual’s perceived susceptibility to a disease, the individual’s perception of illness severity, the individual’s rational perception of benefits versus cost and finally the individual’s cues to action which is dependent on media, friends, family or well known citizen who can provide an impetus for prevention or treatment. The absence of cues to action will reduce the likelihood of prevention or treatment, thus the individual’s choice to utilize health services is contextually dependent.
Choice making model propounded by Young 1950 incorporated four components that are most essential to the individual health service choice, these includes: perception of gravity of illness, knowledge of home treatment, the faith in remedy and accessibility of treatment which incorporates the individual’s evaluation of cost of health services and the availability of those services. PLP with poor access to treatment center, low income power and poor encouragement from loved ones will find utilization of available ARV drugs very difficult.
According to UNAIDS (2008) Nigeria had 25 treatment centers as at 2004 which was found to be inadequate in helping the large population of people living positive in the country. As a result of this, more 41 new dispensing centers were opened in the nation in 2006 to serve the ever growing population of infected persons. Having set up many dispensing centers in the Nation, the Federal Government developed the national HIV & AIDs strategic framework to manage the Nations response to the syndrome. A number of targets were integrated into the framework and one of such targets as stated by UNAIDS (2008) was that by 2010 Nigeria aimed to provide ARV drugs to 80 per cent of adults and children with advanced HIV infection being treated in all the designated hospitals in various states.
Anambra state being one of the beneficiaries of the federal allocation of treatment centers had eight treatment centers allotted to her (Appendix A) and same were share out to the three senatorial zones of the state to ensure fare treatment to all. All hands were on deck to ensure that the National target was achieved as stipulated. Surprisingly the state was still rated as one of the HIV “hot spot” states meaning that prevalence rate was still very high. The high prevalence rate in the state points to the fact that weakness exists in the stem of administration in state. As stated by Peterson and Obileye (2002) the word used to describe drug distribution in Anambra State was “Chaotic”. Pharmacists have lost control and there are few enforcement efforts to curb illegal activities. Problem of parallel importation of counterfeit drugs and drug dumping have led to questions of safety, efficacy and quality of ARV drugs available and accessible in Anambra State. In the light of this, the study seeks to establish whether ARV drugs are available and utilized, it also investigates the extent of availability and utilization of the drugs based on the socio-demographic factors.
Statement of the Problem
ARV drugs used for the treatment of HIV/AIDS should be readily available and easily accessible by all the people living positive no matter the location, economic status, educational qualification, marital status and gender among others especially as, the drugs are presumed to be free of charge. Available stock should not be allowed to be totally used before replacement to avoid the out of stock syndrome in the designated hospitals. This is because withdrawal from treatment could be detrimental to the life of the PLP.
Regrettably, PLP find it difficult to have access to ARV drugs. Although the designated hospitals are there to provide these drugs, yet some of the PLP shy away from collecting the drugs. This may be as a result of stigmatization, hidden cost and distance. On utilization when the PLP come to collect the drugs they may be faced with out of stock syndrome in the designated hospitals. The situation affects the PLP adversely because adherence to treatment may be lacking. Some of the health workers in the state stigmatize the PLP and this scares the PLP from coming to the designated hospitals regularly for treatment.
Most Africans living positive do not seem to have access to ARV drugs as evidenced by USAID report. Besides fewer than one in five of the millions of Africans in need of treatment are receiving it. Many millions are not even receiving treatment for opportunistic infections, which affects individuals whose immune system have been weaken by HIV infection. This situation may not be too different in Anambra State.
The situation also is devastating on the ARV drugs programme because without adequate availability and utilization of the drugs there may be increase in the PLP mortality in the State. The study therefore sought to find out the extent of availability and utilization of ARV drugs in Anambra State.
Purpose of the Study
The purpose of this study is to determine the availability and utilization of ARV drugs for the treatment of HIV&AIDS in designated hospitals in Anambra State. Specifically the study focused on finding out the extent of: