Factors associated with adherence to antiretroviral therapy among HIV infected children in Kabale district, Uganda: a cross sectional study
Wadunde et al. BMC Res Notes
Factors associated with adherence to antiretroviral therapy among HIV infected children in Kabale district, Uganda: a cross sectional study
Ignatius Wadunde 0
Doreen Tuhebwe 0
Michael Ediau 0
Gildo Okure 0
Arthur Mpimbaza 2
Rhoda K. Wanyenze 1
0 Department of Health Policy, Planning and Management, Makerere University College of Health Sciences School of Public Health , P.O Box 7072, Kampala , Uganda
1 Department of Disease Control and Environmental Health, Makerere University College of Health Sciences School of Public Health , P.O Box 7072, Kampala , Uganda
2 Child Health and Development Centre, Makerere University College of Health Sciences School of Medicine , P.O. Box 6717, Kampala , Uganda
Objectives: This study was set out to assess the level of adherence to antiretroviral therapy (ART) and its determinants among children receiving HIV treatment in Kabale district, south western Uganda, in order to inform interventions for improving pediatric ART adherence. Results: Overall, 79% (121/153) of the children did not miss ART doses over the 7 days. Caregiver forgetfulness was the major reason for missing ART doses, 37% (13/35). Other reasons included transportation costs to the health facilities, 17%, (6/35) and children sitting for examinations in schools. Older children (11-14 years) were more likely to adhere to ART than the younger ones (0-10 years) (AOR = 6.41, 95% CI 1.31-31.42). Caregivers, who knew their HIV status, had their children more adherent to ART than the caregivers of unknown HIV status (AOR = 21.64: 95% CI 1.09-428.28). A significant proportion of children in two facilities 21.5% (32/153) missed ART doses within the previous week. Support for providers to identify clues or reminders to take drugs, extending HIV testing to caregivers and innovative models of ART delivery that alleviate transport costs to caregivers and allow sufficient drugs for children in school could enhance drug adherence among children.
Pediatric; Adherence; Antiretroviral therapy
Antiretroviral therapy (ART) improves health and
prolongs the lives of persons with HIV [
] and in
children, adherence to ART reduces viral load [
AIDS related morbidity  and mortality [
to ART has rapidly expanded globally and in sub
Saharan Africa especially with the most recent changes in the
World Health Organization (WHO) guidelines to allow
early treatment for HIV infected individuals .
However, implementation of ART among children 0–14 years,
faces major challenges of adherence [
Better Socio-economic status and well tolerated
regimens are associated with better adherence [
factors like socio-demographic and socio-cultural
factors, side effects of ARVs, ART regimes, drug dosing
], duration on ART , health of child [
knowledge of their HIV status [
], and psychosocial
factors such as stress, depression and anxiety [
] have also
been associated with pediatric ART adherence [
The Care giver report has been used as a simple and
vital method in assessing pediatric ART adherence in
5, 11, 17
Thirteen percent of the people living with HIV/AIDS in
Uganda are children [
], and all HIV positive
children less than 15 years (0–14) are initiated on ART
irrespective of the CD4 count or WHO clinical staging .
To ensure retention in HIV care and adherence to HIV
treatment, there should be constant supply of
antiretroviral drugs (ARV’s), psychological support and HIV status
disclosure by care giver with support of a counselor for
children aged 10 and above [
9, 20, 21
In Kabale district, there were 564 HIV positive
children aged 0–14 years and reports from the district health
office indicated low adherence to ART. This study set out
to determine the level of adherence and its associated
factors among HIV infected children aged 0–14 years in
Kabale district, so as to inform efforts for improving ART
adherence among HIV infected children.
We conducted a quantitative cross sectional study
between June and August 2014 in Kabale district located
in south western Uganda, with an estimated regional HIV
prevalence of 5% [
]. The district has twenty two
health facilities providing pediatric ART; however, this
study was conducted in two hospitals of Rugarama
(private) and Kabale regional referral (public). These
hospitals were deliberately selected because they provide HIV
treatment to the largest number of HIV infected children
in the district.
We interviewed 153 caregivers of HIV infected
children aged 0–14 years receiving ART in the two
hospitals. The caregivers had to be 18 years and above, age at
which they could give informed consent and the eligible
children were those who had been on ART for at least
3 months prior the interview. This study, since it was a
cross sectional study, the sample size was determined
from the formula for estimating sample sizes for
prevalence studies [
The caregivers of the sampled children were
interviewed using a pre-tested, semi-structured questionnaire
translated into Rukiga, the predominant local language
in Kabale district. The interviews were administered by
trained study nurses fluent in Rukiga, the local language.
We assessed several factors that were suspected to
influence ART adherence as informed from the
literature review. The child related factors included age and
health status of the child, knowledge of their HIV status
and duration on ART [
] . The caregiver factors
included the caregiver’s relationship with the child, stress
and depression, age, sex, occupation, highest level of
education attained, and duration as child’s caregiver [
]. The drug regimen for each child was documented
in addition to the other medication factors such as side
effects of the ART, drug dosing and tolerability [
5, 11, 15
We also assessed caregiver forgetfulness to remind their
HIV infected children on ART to take their medication
on time, since it has been found to affect the child’s
The dependent variable was adherence to ART in the
last 7 days as reported by the caregiver. Adherence
measurement was based on the caregivers report of missed
ART doses in the last 7 days prior to the interviews [
and similar adherence studies used a 3 days recall [
It was characterized as “optimal adherence versus poor
adherence”. Children whose caregivers reported no
missed doses were considered to have optimal adherence
to ART while those who reported one or more missed
doses were considered to have poor adherence.
After questionnaires had been checked, the data was
entered using Epi Info software and exported to Stata
software for analysis. At Univariate analysis, categorical
variables were analyzed using frequencies and
proportions and continuous variables using means and standard
deviations. The percentage of children with good
adherence was calculated by dividing the number of care givers
who reported that their children did not miss any dose
within the last 7 days prior the interview by the total
number of caregivers interviewed.
Bi-variable analysis was done to determine the
relationship between each independent factor and adherence.
Multivariate logistic regression was done on all factors
that were significant after bi-variable analyses to
identify factors independently associated with ART
adherence. The association of independent variables with the
dependent variable was measured using odds rations and
the corresponding 95% confidence intervals (CI). A p
value of < 0.05 was considered statistically significant.
Results and discussion
All the 153 caregivers who were approached agreed to
participate and were interviewed. Most of the sampled
children (84.3%, 129/153) were enrolled from Kabale
regional referral hospital. Most of the caregivers were in
the 31–40 year age group, 40.1%, (62/153), and majority
of the caregivers were females, 73.9% (113/153), had
primary level of education 37.9% (58/153), were peasants,
47.6% (70/153) and 78.4% (120/153) were biological
parents of the children. Of the 153 children, 56.2% (86/153)
were females and the majority, 85.1%, (131/153) were
above 5 years of age.
Details of the socio-demographics for the children and
caregivers are shown in Table 1.
Level of adherence to ART
Overall, 79.1% (121/153) of the children did not miss any
ART doses over the 7 days. Thirty-five children (20.9)
missed at least one dose within a period of 7 days. The
commonest reasons for missing doses were forgetfulness,
34% (13/35), transportation costs to the health facilities,
17% (6/35) and children sitting for examinations at
school, 17% (6/35).
Seventeen caregivers reported various side effects of
ART including dizziness, 23% (4/17), vomiting, 18%
(3/17), stomach pain, 11% (2/17), rashes, 18% (3/17),
headaches, 18% (3/17) and fever, 11% (2/17) (Table 2).
Factors associated with adherence to antiretroviral therapy
After controlling for child age, duration on ART,
knowledge of their HIV status, age of caregiver, caregiver level
of education, caregiver relationship with child and
caregiver knowing their HIV status, child age and caregiver
knowledge of their HIV status had significant
associations with adherence.
Reasons for missing dose
Children went playing
Child vomited drug
Drug run out
Older children (11–14 years) were more likely to adhere
to ART than the younger ones (0–10 years) AOR 6.41
(95%CI 1.31–31.42) p-value 0.022. Children of Caregivers
who knew their HIV status were more likely to adhere to
ART than those whose caregivers did not know their HIV
status AOR 21.64 (1.09–429.24) p-value 0.044 (Table 3).
Caregiver forgetfulness was a major (37%) reason for
missing ART doses. This can be improved by advising the
caregivers to give the children the medicines consistently
at the same convenient time of the day and using clues
to remind them to give the child their drugs [
other reason for missing ART doses were transportation to
facilities for drug refills. Transportation cost as a limitation
for appointment keeping and drug refills has been reported
by studies among children and adults [
based refills for stable patients can alleviate such challenges
and also improve efficiencies for service delivery [
Our study found that older children (11 years and above)
were more likely to adhere to ART than younger ones
(0–10 years), and this is in line with findings from Ethiopia
]. Older children have better awareness and
appreciation of the negative effects of poor ART adherence,
especially if their HIV status has been disclosed to them [
Providers should thus pay more attention to the younger
children and provide support to caregivers to bridge the
Our study also found that caregivers who knew their
HIV status, had their HIV infected children more likely to
adhere to ART compared to the children of the
caregivers who did not know their HIV status. This implies that
all caregivers of HIV infected children should be advised to
know their HIV status, enhances their HIV infected
children to adhere to their medication.
The level of adherence to antiretroviral therapy was
found to be sub optimal, a significant proportion of
children, 21% (35/153) missed their drugs.
Caregiver knowledge of their HIV status was
associated with pediatric ART adherence, so there is need to
integrate efforts to enhance caregivers of HIV infected
children to know their HIV status. Caregiver
forgetfulness and transportation challenges also led to missed
In our study, we recognize a major limitation of the use
of a small sample size (153) that gave rise to very wide
confidence intervals. Caregiver reports of missed ART
doses to assess adherence, is also a less objective
measure of adherence because it leads to over estimation of
adherence, recall bias and social desirability bias.
ART: adherence to antiretroviral therapy; ARV’s: antiretroviral drugs; CI:
confidence interval; HDREC: Higher Degrees Research and Ethics Committee; WHO:
World Health Organization.
IW: Conceived and implemented the study, supervised data collection,
analyzed the data and wrote the first version of the manuscript. DT, ME,
AM and GO supported IW in conceptualizing and designing the study and
participated in data analysis, interpretation of results and reviewed the draft
manuscript. RKW: Participated in data analysis, interpretation and reviewed
the draft manuscript for substantial intellectual content. All authors read and
approved the final manuscript.
We thank the study participants for their participation in the study. We would
also like to extend our heartfelt gratitude to the study Nurses (Research
Assistants) at Kabale regional referral hospital and Rugarama hospital who helped
with data collection.
The authors declare that they have no competing interests.
Availability of data and materials
Data used in this analysis are made available to all interested researchers upon
request directed to the author Mr. Wadunde Ignatius ().
Consent for publication
Ethics approval and consent to participate
Ethical clearance was obtained from the Makerere University School of public
Health Higher Degrees Research and Ethics Committee (HDREC) and
permission sought from relevant officials in the district and selected health facilities.
All consent forms were translated into the local language (Rukiga) and
backtranslated into English to ensure correct use of language. Consent forms were
read aloud to caregivers by trained study nurses. The consent forms described
the purpose of the study, procedures involved, and the risks and benefits of
participation. Consent was obtained from a parent or caregiver on behalf
of the participants who were under the age of 16. The interviews were
conducted in private rooms and confidentiality of data protected through the use
of identification numbers rather than names and limiting access to the data.
This study was funded by Makerere University School of Public Health through
Cooperative Agreement Number: 5U2GGH000817-03 (“Provision of
Comprehensive HIV/AIDS services and developing national capacity to manage
HIV/AIDS Programs in Uganda”) from the US-Centers for Disease Control and
Prevention. The contents of this article are however solely the responsibility
of the authors and do not necessarily represent the views of the US-Centers
for Disease Control and Prevention and Makerere University School of Public
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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