Inclusion criteria: PLHIV

All involved PLHIV were above 19 years and had started with ART at least six months before
July 2011. The selection considered those who had attended the clinic from July to
December 2011, as this is the latest period for which the facility reported adherence levels
among its PLHIV on ART. All of the staff interviewed joined the clinic after 2005; therefore
they had enough interaction, experience and understanding of patients as well as
procedures of service provision within the clinic.
Exclusion criteria:
All adult PLHIV who were on ART were eligible for this study except those who were lost to
follow-up and who could not be found/traced back by the institution. Respondents who were
not ready to participate and those who refused to sign consent forms were excluded. Two
PLHIV (one male and one female) participants refused to sign consents so that replacement
was done by considering the type of variables they were selected for
Adherence to antiretroviral therapy has been reported to result in successful treatment
outcomes (Paterson et al. 2000; Penn et al. 2011; Rougemont et al. 2009; Wang et al. 2009).
It is urged that plasma viral loads should be undetectable after six months of ART; otherwise
poor adherence is associated with the failure (WHO, 2006). Suboptimal adherence to ART has
been significantly associated with treatment failure and drug resistance among PLHIV
receiving ART in India (Ekstand et al. 2011). The study reported a median detectable viral
load of 8850 copies/ml, in which 42% of patients had suboptimal adherence. Moreover,
treatment interruption and adherence fluctuation due to the alternation of pill taking
proclaim high effects in viral load suppression (Ncaca et al. 2011). Figure 2 below indicates
the association of ART adherence and virological failure
According to Paterson and other subsequent evidence, ART adherence of at least 95% is
associated with good treatment outcome and virological suppression (Ndubuka et al. 2010;
Lanience et al. 2003; Mannheimer et al. 2006b). However, In one hospital in Central Nigeria,
adherence was insignificant to treatment outcome. In this setting, PLHIV were found with
good CD4 counts after 18 months of initiation, although adherence was less than 80% (Agu
et al. 2010). However, this study used only CD4 counts to assess treatment effectiveness
instead of combining with the measurements of viral strain. CD4 cells have rapid fluctuation
and can therefore not be used alone to reflect ART effectiveness. Moreover, in West Africa
adherence to ART was significant to CD4 cells increase but insignificant to viral suppression
(Massou et al. 2008)
As indicated above, suboptimal adherence to ART affects both individuals and the general
society. At the individual level, it increases AIDS progression and at a national level it
ultimately increases morbidity and mortality (Ramadhan et al. 2007; Ferradini L. 2006).
Suboptimal adherence may cause mutations of virus, hence drug resistance. Mostly this
leads to changes in treatment regimens and in turn to higher costs. Near future patients in
resource-poor settings might require transfer of first-line to second-line regimens due to
treatment interruptions, which are costly, complicated and toxic (WHO, 2011b

Background: The introduction of Antiretroviral Therapy (ART) has shown a tremendous reduction in HIVrelated mortality and morbidity in people living with HIV / AIDS. Adherence to ART is the key to a
successful treatment outcome. This study investigates the adherence of people living with HIV who are on
ART. Since high levels of adherence of more than 95% are required to achieve effective suppression of
the viral load, the researcher finds it very important to establish whether the people are pursuing what is
expected of them. While the use of ART has brought much excitement and hope to both patients and
medical practitioners in the world, it has also brought many new questions and challenges, including
adherence issues. Adherence is, therefore, essential to achieve the success of ART.
Aim: The main objective was to determine which factors influence adherence to ART among HIV and
AIDS patients.
Methods: This study utilised a qualitative cross-sectional descriptive design that was conducted at
theJamshedpur, East Singhbhum Jharkhand India.. Data was collected using a structured questionnaire
with open- and closed-ended questions where a total of 20 respondents were interviewed. Data was
analysed and data was presented by descriptive and inferential statistics
Results: The findings indicated that the adherence to ART at the Kwa-Thema Clinic was 77%. Factors
that were significantly associated with adherence were gender (( 2 = 3.78, df = 1, p < 0.05).), level of
education ((2 = 3.52, df = 3, p = 0.032), co-treatment of HIV and other infections ( 2 = 5.46, df = 4, p =
0.019).), ability to follow ART ((2 = 12.82, df = 1, p = 0.000 < 0.05), and types of ARV drugs.
Recommendation: To enhance ART adherence the study recommends intensification of health education
campaign against stigma and gender discrimination. Providing feedback to the patients by the healthcare
providers regarding the benefits of ART is important.
Conclusion: It was concluded that the adherence to ART at the Kwa-Thema Clinic was sub-optimal (less
than 95%) at 77% but comparable to the adherence levels in other developing countries.

Abstract
Background: An antiretroviral therapy (ART) adherence of at least 95% has been proven
necessary in order for treatment to be effective. Failure to meet this level results in poor
immunological and virological outcomes.
Objective: The objective is to explore factors influencing ART adherence among adult
people living with HIV (PLHIV) on ART for at least 6 months at Mnazi Mmoja Care and
Treatment Centre (CTC) in Zanzibar.
Method:
A qualitative exploratory study: Sixteen people were recruited for in-depth interviews
(IDI). Four focus group discussions (FGD) with PLHIV on ART were also conducted.
Literature review: Publications were collected on interventions and strategies to improve
ART adherence.
Results: Factors that were shown to impede ART adherence include the use of traditional
medicines, stigma, forgetfulness, false beliefs about HIV, and alcohol/illicit drug use. Other

factors are side effect, pill burden, improper treatment monitoring and support, lack of food,
hunger, economic hardship.
Factors enhancing ART adherence included acceptance of HIV status, desire to be healthy
and live longer, disclosure, social support, treatment efficacy and adequate drug supply.
The key interventions/strategies were use of treatment assistant, use of medication
reminders, task shifting and home-based care (HBC) services.
Conclusion: The adherence among PLHIV on treatment can be improved through
appropriate interventions/strategies.
Recommendations: The Ministry of Health should strengthen stigma reduction campaigns
to promote disclosure and increase social support to PLHIV. The Ministry should also execute
study to examine possible interaction between ART and traditional medicines.
Key words: Adherence, factors, antiretroviral therapy, people living with HIV, Tanzania

DATA SATURATION
Theoretical saturation of data is a term in qualitative research, mostly used
in the grounded theory approach. Theoretical saturation of data means that
researchers reach a point in their analysis of data that sampling more data
will not lead to more information related to their research questions.(1) No
additional data can be found to develop new properties of categories and
the relationships between the categories are disentangled. Researchers see
in their data similar instances over and over again and that make them
empirically confident that their categories are saturated, the descriptions of
these categories are thick and a theory can emerge. Researchers are
allowed to stop sampling data and to round off their analysis.
Explicit guidelines for determining theoretical saturation are lacking and
therefore researchers have to support their claims of saturation by an
explanation of how they achieved saturation including clear evidence.(2)
The application of the term saturation beyond the grounded theory
approach is a topic of debate.(3)

(1) Seale C. Grounding theory. In: Seale C, editor. The Quality of Qualitative
Research.London: SAGE Publications Ltd; 1999. p. 87-105.
(2) Bowen GA. Naturalistic inquiry and the saturation concept: a research
note. Qualitative Research 2008;8(1):137-52.
(3) OReilly M, Parker N. Unsatisfactory Saturation': a critical exploration of
the notion of saturated sample sizes in qualitative research. Qualitative
Research 2013;13(2):190-7.

Grounded theory (GT) is a systematic methodology in the social

sciences involving the construction of theory through the analysis of data. [1]
[2]
Grounded theory is a research methodology which operates almost in a
reverse fashion from social science research in the positivist tradition.
Unlike positivist research, a study using grounded theory is likely to begin
with a question, or even just with the collection of qualitative data. As
researchers review the data collected, repeated ideas, concepts or elements
become apparent, and are tagged with codes, which have been extracted
from the data. As more data are collected, and as data are re-reviewed,
codes can be grouped into concepts, and then into categories. These
categories may become the basis for new theory. Thus, grounded theory is
quite different from the traditional model of research, where the researcher
chooses an existing theoretical framework, and only then collects data to
show how the theory does or does not apply to the phenomenon under
study
Stage

Purpose

Codes

Identifying anchors that allow the key points of the data to be

gathered

Concept
s

Collections of codes of similar content that allows the data to

be grouped

Categori
es

Broad groups of similar concepts that are used to generate

a theory

Theory

A collection of categories that detail the subject of the research

Once the data are collected, grounded theory analysis involves the following
basic steps:
1. Coding text and theorizing: In grounded theory research, the search for
the theory starts with the very first line of the very first interview that
one codes. It involves taking a small chunk of the text where line by
line is being coded. Useful concepts are being identified where key
phrases are being marked. The concepts are named. Another chunk of

text is then taken and the above-mentioned steps are being repeated.
According to Strauss and Corbin, this process is called open coding and
Charmaz called it initial coding. Basically, this process is breaking data
into conceptual components. The next step involves a lot more
theorizing, as in when coding is being done examples are being pulled
out, examples of concepts together and think about how each concept
can be related to a larger more inclusive concept. This involves the
constant comparative method and it goes on throughout the
grounding theory process, right up through the development of
complete theories.
2. Memoing and theorizing: Memoing is when the running notes of each
of the concepts that are being identified are kept. It is the intermediate
step between the coding and the first draft of the completed analysis.
Memos are field notes about the concepts in which one lays out their
observations and insights. Memoing starts with the first concept that
has been identified and continues right through the process of
breaking the text and of building theories.
3. Integrating, refining and writing up theories: Once coding categories
emerges, the next step is to link them together in theoretical models
around a central category that hold everything together. The constant
comparative method comes into play, along with negative case
analysis which looks for cases that do not confirm the model. Basically
one generates a model about how whatever one is studying works
right from the first interview and see if the model holds up as one
analyze more interviews.
Theorizing is involved in all these steps. One is required to build and test
theory all the way through till the end of a project. [9]
Why Measuring Adherence Is Important
Adherence to treatment is critical to obtain full benefits of ART including
maximum and
durable suppression of viral replication, reduced destruction of CD4 cells,
prevention of viral
resistance, promotion of immune reconstitution, and slowed disease
progression. With an
effective regimen that is fully suppressive to viral replication, nonadherence
is the single
most important factor that can lead to viral resistance. WHO16 recommends
that accurate
assessment of adherence is necessary for effective and efficient treatment
planning. Decisions to change recommendations, medications, and/or

communication style to promote adherence depend on valid and reliable

measurement of adherence. Without formal assessment, providers are
unlikely to accurately identify adherent and nonadherent patients, missing
the
opportunity for reinforcement and constructive interventions respectively. If
adherence is
below optimal and drug levels are low, viruses continue to replicate. HIV is
highly adaptive
to viral-suppressing pressures and can rapidly mutate to develop resistance.
Another reason
why adherence is important is that HAART may still improve CD4 cell levels
despite
ongoing viral replication because the mutant viruses which emerge are less
fit and less
destructive than wild-type HIV.
Patersons et al pioneer study established that up to 95 percent adherence
is necessary for
HIV viral suppression. The study linked the relationship between adherence
and viral load
(VL); as adherence decreased, VLs increased sharply in a dose-response
effect. The study
was able to conclude that greater adherence levels were associated with
greater reduction in
VLs. Generalizing Patersons findings to the less developed countries may
require taking the
following gaps into considerationsmall number of patients; only protease
inhibitors
patients studied; patients did not have formal institution-based adherence
education, and
MEMScap, which is not easily available in developing countries, was used.
However, other
studies have confirmed Patersons study and the relation between
adherence and treatment
outcomes; there is evidence that for every 10 percent decrease in
adherence, there is a 16
percent increase in HIV-related mortality.19
Therefore, adherence needs to be measured in clinical settings. Accurate
and reliable
measures of adherence and better understanding of both barriers and
facilitators of adherence
are needed to help clinicians identify patients who need assistance with
their pill taking, to
design and evaluate effective interventions to enhance adherence, and to
interpret the role of

adherence in evaluating clinical outcomes and making treatment

decisions.20 Measuring
adherence to ART is even more challenging due to evolving evidence that
different classes of
ARVs may require difference adherence levels to sustain virological
suppression. The
responses seen in the different class-specific adherence-resistance
relationships indicates that
there may be differences in the manner the HIV responds to different levels
of adherence.
16 WHO. 2003. Adherence.
17 Miller, V., C. Sabin, A. Phillips, et al. 2000. The impact of protease
inhibitor containing highly active
antiretroviral therapy on progression of HIV disease and its relationship to
CD4 and viral load. AIDS 14(14):
2129-2136.
18 Paterson, D.L., et al. 2000. Adherence. Ann Intern Med.
19 Hogg, R., B. Yip, K. Chan. 2000. Nonadherence to triple combination
therapy is predictive of AIDS
progression and death in HIV-positive men and women. Paper presented at
the 13th International AIDS
Conference, July 9-14, Durban, South Africa.
20 Wagner, G. 2004. Measuring Instruments and Predictors in Medication
adherence in HIV/AIDS. In
Medication Adherence in HIV/AIDS edited by Jeffrey Laurence. New York:
Mary Ann Liebert, Inc.
Literature Review on Measuring Adherence
5
However, in general, the current ARVs do not provide adequate therapeutic
coverage (nonforgiving)
when patients intermittently forget to adhere. Levels of adherence that had
historically been regarded as good enough for other chronic diseases has
been found not to
be good enough for ART. Good enough adherence (sub-optimal adherence
to suppress
viral replication) may predispose to a situation where drug pressure selects
resistant virus. To
be in a position to identify adherence problems (irrespective of which class
of ARV patients
are on) and develop interventions to improve it, adherence measurement is
fundamental and
improved tools need to be developed to assess adherence.