Audit of Antenatal Testing of Sexually Transmissible Infections and Blood Borne Viruses at Western Australian Hospitals

In August 2007, the Western Australian Department of Health (DOH) released updated recommendations for testing of sexually transmissible infections (STI) and blood-borne viruses (BBV) in antenates. Prior to this, the Royal Australian & New Zealand College of Obstetricians & Gynaecologists (RANZCOG) antenatal testing recommendations had been accepted practice in most antenatal settings. The RANZCOG recommends that testing for HIV, syphilis, hepatitis B and C be offered at the first antenatal visit. The DOH recommends that in addition, chlamydia testing be offered. We conducted a baseline audit of antenatal STI/BBV testing in women who delivered at selected public hospitals before the DOH recommendations. We examined the medical records of 200 women who had delivered before 1st July 2007 from each of the sevenWAhospitals included in the audit. STI and BBV testing information and demographic data were collected. Of the 1,409 women included, 1,205 (86%) were non-Aboriginal and 200 (14%) were Aboriginal. High proportions of women had been tested for HIV (76%), syphilis (86%), hepatitis C (87%) and hepatitis B (88%). Overall, 72% of women had undergone STI/BBV testing in accordance with RANZCOG recommendations. However, chlamydia testing was evident in only 18% of records. STI/BBV prevalence ranged from 3.9% (CI 1.5– 6.3%) for chlamydia, to 1.7% (CI 1–2.4%) for hepatitis C, 0.7% (CI 0.3–1.2) for hepatitis B and 0.6% (CI 0.2–1) for syphilis. Prior to the DOH recommendations, nearly three-quarters of antenates had undergone STI/BBV testing in accordance with RANZCOG recommendations, but less than one fifth had been tested for chlamydia. The DOH recommendations will be further promoted with the assistance of hospitals and other stakeholders. A future audit will be conducted to determine the proportion of women tested according to the DOH recommendations. The hand book from this conference is available for download Published in 2008 by the Australasian Society for HIV Medicine Inc © Australasian Society for HIV Medicine Inc 2008 ISBN: 978-1-920773-59-

Performance, costs and cost-effectiveness analysis of the Tay Ho HIV integrative prevention and care & treatment outpatient clinic, Vietnam. : is the model worth scale up?

Since the early 1990s, Vietnam has been experiencing an HIV/AIDS epidemic with a general prevalence rate of 0.42 % in 2008 and a projected prevalence rate in 2012 of 0.47%. Although the general HIV prevalence rate is considered low, the virus heavily affects some at-risk population groups in Vietnam, including commercial sex workers, injectable drug users and the men who have sex with men. According to studies, prevalence among these groups is considerable, up to 65%. Risky sexual behaviours are common practice in all three groups, and the chain of infection is intertwined. Besides, the situation is rendered even more complex in respect of HIV transmission prevention and PLHA treatment because of a governmental zero tolerance policy in respect of drug-users and a high level of stigma and discrimination towards PLHA in the Vietnamese society. In that context, the active fight against HIV in Vietnam began in earnest at the end of 2003, with the arrival of one major international donor scheme, namely PEPFAR, followed in 2006 by the start of disbursement of the Global Fund, and the active work of the World Bank and DFID and other bilateral agencies, amounting to US$114 million in the single year 2008. At the same time, the Vietnamese government was spending US$9.7 million on the fight against HIV amounting to less than 1% of the Ministry of Health’s budget. As a consequence, Vietnam became highly dependant on international aid to finance its fight against the epidemic. Meanwhile, it is estimated that about 30% of the needs are covered in terms of prevention activities and medical assistance to PLHA. There is thus a critical need for identifying the most cost-effective models of intervention in the Vietnamese context to help scale-up programmes in the country and meet the needs in respect of both prevention and treatment. It is in this context of limited resources and high social barriers for at-risk population that the French non-governmental organisation, Médecins du Monde, developed an integrated prevention and care model, implemented at the end of 2005 in Tay Ho, a district of Hanoi. The MDM has undertaken both financial and technical support and the main components of its model include a prevention component consisting of a mobile outreach team and the VCT unit, and a care and treatment department including adherence training, support through home-based care and HAART. The assumptions that led Médecins du Monde to implement such of model of action were that integrating prevention, detection, and care & treatment services within the same structure would help better targeting and attracting at-risk populations, hence increase programme performance, and finally build a cost-effective response through cost-savings and internal programme synergies. Goal and objectives The goal of this research is to test the hypothesis on which this model of intervention relies: that the integration of outreach, detection and care & treatment components within the same outpatient clinic, in the Vietnamese context, results in a high caseload of at-risk clients and patients along with structural economy of scale, translating in high cost-effectiveness levels for the model’s key components. As such, the goal of the research translates into the following objectives: ->Assessing model’s outputs by analysing prevention, testing and care & treatment components performance in term of provision, coverage, utilisation and impact ->Analysing central components of the model (VCT and HAART) cost- effectiveness, vs. the null-set scenario, and standards reflected in international literature ->Analysing potential sources of synergies within the program and their impact on the cost-effectiveness level of its key components Method This research is based on a bottom-up three-layer analysis: ->one related to each programme’s component performance and output; ->another related to each programme component's costs and unit costs; and ->a third related to the cost-effectiveness analysis of the programme's two central components, the VCT and the care and treatment services Results are presented as follows: ->A first part presenting performance results ->A second dedicated to the financial and economic analysis, laying out: ->Model’s components financial unit-costs ->Key components – VCT and care & treatment – cost- effectiveness analysis, with two sub-parts, a first one on the analysis of synergies within the model based on financial unit- costs analysis, and a sensitivity analysis based as well on financial unit-costs For each layer, the method of data collection and analysis is designed to address some field-related constraints including that: ->the research is partly based on retrospective data; ->the field is not designed to conduct academic research; and ->the M&E system at field level is limited and cannot be adapted for the purpose of the research. The theoretical foundation of the thesis is founded on: ->Habicht’s guidance on the development of programme performance indicators in terms of provision, coverage, utilisation and impact; ->the World Health Organisation-CHOICE guideline on cost-effectiveness analysis; and ->an adaptation of the step-down accounting methodology to allocate indirect costs in a systematic fashion and ensure transferability of the results Findings The underlying hypothesises supporting the implementation of that model of intervention combining prevention and care & treatment components proved true. The model promoted strong synergies, which contributed to the increase in numbers of patients attending at the OPC level. Critical harm reduction activities could be carried out directly in the city’s hotspots while at the same time the mobile outreach team was identifying potential PLHA in need of a treatment. The concentration of these two functions within one team reduced the cost per client referred for VCT, and helped to raise awareness of existing medical services offered by the OPC targeting directly the most at-risk populations. The integration saved as well costs by boosting the demand for the clinic’s services and the use of the significant resources invested in the setting up of such a model in term of fixed capital and trainings. The model worked as a system with positive feedback loops preventing new infections and actively treating identified People Living with HIV/AIDS through levelling off social barriers. This system worked not only from outreach to treatment, but certainly as well from treatment to outreach by increasing VCT attraction, at-risk persons being aware of the presence of immediately free medical services within the same structure. As calculated in our research, the average ICR of the VCT unit vs. the null set scenario was 12 I$/DALY(3,0) averted, well below World Health Organisation- CHOICE SEAR indicator of 40 I$, and 252 I/DALY(3,0) averted for the care & treatment unit, well in line with international standards. A model in which outreach and detection services were not integrated with care and treatment service would have increased unit costs (by a factor of four (4)), resulting in the medical component running costs per DALY averted far below international standards. The same would have been the case had the VCT unit not been integrated with the mobile outreach service, at least in the first two (2) years of the programme's operation. Integrating the mobile outreach team with the services offered by the VCT unit, cut costs to the latter by a factor of three (3). Nonetheless factors related to adherence to treatment and the delay in identifying patients for testing and treatment hampered the global cost- effectiveness of the programme. Conclusion The model is cost-effective, yet limited. First, the demonstrated synergy highly depends on the context in which the programme operates. Were the prevalence in the target population to decrease below 15%, the synergy between the mobile outreach team and the VCT unit would begin to disappear. Moreover, were VCT services to be mainstreamed in Vietnamese society, the extra-cost incurred by the work of the mobile outreach team would hinder this synergy. Second, because of contextual limitations the model showed only an average cost-effectiveness by international standards, especially within its medical component. The model was unable to retain pre-ARV patients in sufficient numbers, or to convince them to abide by the OPC protocols in the absence of critical complementary services, such as Methadone Maintenance Therapy, and/or early access to ART. The introduction of a Methadone Maintenance Therapy in an environment in which about 60% of PLHA are opiate-users would change dramatically the outcome of HAART, not to mention reducing HIV transmission. Third, in our views, the main limiting issue of this model might be the intense technical support it needed to be implemented and supervised. Indeed, the presence of an external NGO, such as MDM, though necessary in the international co-operation scheme, added critical costs to that programme. Over three years, the share of NGO expenses was considerable, amounting to 58.1% of the total. This cost share reflected the complexity of setting up the programme in the Vietnamese environment and the necessity to channel international funding, control spending, report to donors, and ensure the overall technical supervision of the model. Besides, costs also rose because the general NGOs co-operation system in Vietnam creates significant market distortions as a result of a limited local pool of skilled labour creating niche job markets. It is hence likely that the international system in place inflated costs at the NGO level by creating not only job-market distortions, but also several time- consuming tasks, such as reports, proposal writing, seeking fund prolongation agreements, and juggling different accounting and report norms. As such, the question remains on how transfer both financial and technical burden to local authorities in a context of limited resources. The Vietnamese government spends US1,100,000,000 on health care according to official figures from the National Office of Statistic, representing an expense per citizen of US$13.75, including general administrative costs. The sole medicine cost if the current number of PLHA (240,000) in Vietnam were to have access to first-line HAART rises to a minimum US$24,000,000 per year (or 3% of the total health budget), excluding medicines and management costs. Apply the model’s average cost to follow-up a patient for one year of HAART, including medical management and biological follow-up in an optimal situation (average caseload of 750 patients), and that cost would exceed US$200,000,000 a year, (or almost 20% of the annual health budget). This excludes integrating general supervision and management costs, which, depending on the efficiency of the system put in place by the Vietnamese authorities, could add an extra 30% to the total. It seems that in the long term, the matter of the context and technical assistance are central. Though cost-effective and well adapted to the current constraints of the Vietnamese environment, the Tay Ho OPC approach is only a short-term solution until prevention and detection activities are mainstreamed and social obstacles lifted off. It could well be the best model to address HIV/AIDS in the Vietnamese context, or in any other places where concentrated epidemics are evident to quickly break an epidemic. Yet, the issue of the social and financial sustainability of such models remains and should be specifically explored. As such, it appears that research in the future should start focusing not only on the best mix of activities, but on the best model of technical assistance delivery, transfer and sustainability

A best-practice guideline for facilitating adherence to anti-retroviral therapy for persons attending public hospitals in Ghana

The retention of persons on an HIV programme has been a global challenge. The success of any strategy to optimize adherence to anti-retroviral therapy (ART) depends on the intensive and effective adherence counselling and strategies. It is important to research whether persons receiving anti-retroviral therapy in public hospitals in Ghana are receiving the needed service that would optimize their adherence to the anti-retroviral therapy. Therefore, this study explored and described the experiences of healthcare professionals providing care, support and guidance to persons on ART at public hospitals in Ghana, as well as the best-practice guideline that could contribute to facilitating the ART adherence of patients. This study also explored and described the experiences of persons living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) on ART, regarding their adherence to the therapy. The study was organized into three phases. In Phase One: a qualitative, exploratory, descriptive and contextual design was employed. The research population included healthcare professionals, providing services at the HIV clinic at the public hospitals in Ghana, namely the Korle-Bu Teaching Hospital; the 37 Military Hospital and the Ridge Hospital. The healthcare professionals comprised of doctors, nurses, pharmacists and trained counsellors employed in any of the three public hospitals. Persons receiving ART at any of the three public hospitals were also part of the research population. Semi-structured interviews were conducted with healthcare professionals and persons receiving ART. Data were collected from healthcare professionals in relation to their experiences regarding the provision of ART services, their understanding of evidence-based practice and best-practice guidelines, as well as data on the experiences of persons receiving ART in relation to their adherence to the therapy. The data were analysed using Creswell’s six steps of data analysis; and the coding of the data was done according to Tesch’s eight steps of coding. Trustworthiness was ensured by using Lincoln and Guba’s framework which comprised credibility, transferability, dependability, confirmability and authenticity. Ethical principles such as beneficence and non-maleficence, respect for human dignity, justice, veracity, privacy and confidentiality were considered in the study. In phase two, the literature was searched by using an integrative literature review approach and critically appraising the methodological quality of the guidelines in order to identify the best available evidence related to adherence to ART. In Phase Three, a best-practice guideline for facilitating adherence to ART was developed for public hospitals in Ghana based on the findings of the empirical research of Phase One and the integrative literature review in Phase Two. The guideline was submitted to an expert panel for review; and it was modified, according to the recommendations of the panel

Nurses knowledge, attitudes and practices towards patients with HIV and AIDS, Kumasi, Ghana

Studies on knowledge, attitudes and practices among healthcare workers involved in HIV and AIDS care have often revealed the lack of knowledge about HIV and AIDS. Nurses‘ knowledge may compromise the quality of care and attitudes towards patients living with HIV/AIDS. Special nursing knowledge and skills have been suggested as a prerequisite for taking care of patients with HIV. The purpose of this study was to assess nurses‘ knowledge, attitudes and practices towards patients with HIV and AIDS in Kumasi, Ghana. A quantitative cross-sectional study was conducted among 247 nurses at five selected health facilities in Kumasi. Data was collected by means of a structured self-administered questionnaire and analysed using SPSS version 23.0. Results were presented using charts and tables. Knowledge of HIV and AIDS was satisfactory but some of the nurses still hold erroneous beliefs and misconception about HIV transmission. A majority demonstrated favourable attitudes. Nurses had fears of contracting the virus, which resulted in the display of negative attitudes by some. Their practice of universal precautions was satisfactory; however, there was evidence of noncompliance among some of them. More studies should be conducted throughout the country to further assess nurses‘ knowledge, attitude and practices towards HIV and AIDSHealth StudiesM.A. (Nursing Science

Molecular characterisation of hepatitis B virus isolated from human immunodeficiency virus-infected adults at various time points after the initiation of antiretroviral therapy

Dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Medicine November 2017Sub-Saharan Africa is a high endemicity region of both Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) infection. There is a paucity of information in this highly endemic region on molecular evolution of HBV in HIV-infected individuals receiving longterm Lamivudine (Lam) therapy. This study aimed at characterizing the molecular evolution of HBV in HIV-infected black Southern Africans prior-to the initiation of a Lam- containing antiretroviral (ARV) drug regimen, and 3, 6, 12 and 18 months post-initiation. HBV viralloads were quantified using real-time PCR and used to determine the viral suppression in 39 participants from the Shongwe Hospital in rural Mpmualanga, Republic of South Africa. The study participants included 16 participants who were HBsAg+ and 23 HBsAg- at baseline. Of the HBsAg- participants, 19 remained negative throughout follow-up these were defined as the HBsAg- group. The remaining 20 participants were HBsAg+ at baseline and/or at one time-point during follow-up, are referred to as the HBsAg+ group, nine were HBsAg+ throughout the study. Seven participants sero-converted to HBsAg- at a median of 4.2 months, two participants gained the HBsAg at 18.3 months. Two participants were HBsAgat baseline, thereafter became sero-positive but had retro-converted to HBsAg- by last timepoint. A significant finding between these two HBsAg serological groups, was a higher viral suppression achieved in the HBsAg- group -100%, with the HBsAg+ group achieving 13.54% HBV suppression (p = 0.01). HBV was fully suppressed in ten participants, with no suppression found in the remaining participants 29, of which 10 experienced a virologic breakthrough (VBT). HBsAg-negativity was a predictor of viral suppression, with ten HBsAg-negative participants achieving full suppression of HBV (p = 0.01). The NS VBT+ group had a significantly higher percentage of viral suppression, 51,90%, compared to the NS VBT- group 14,35%, despite the VBT events (p = 0.03). Biochemical analysis revealed that baseline alanine transferase (ALT) levels were significantly lower in the full suppression (FS) group indicating that lower ALT levels are a predicator of viral suppression (p = 0.02). Participants in the FS group had significantly lower ALT levels (15.5) at baseline compared to the NS group (35) (p=0.02). Another finding of the study was that only participants belonging to the HBsAg-negative group were able to clear the HBV virus whereas HBsAg positivity at any time point precluded clearance of HBV DNA. The Basal Core Promotor/PreCore (BCP/PreC) and complete surface (S) regions were amplified and sequenced to genotype HBV isolated from this cohort, as well as find detection or immune escape mutations. The majority of HBV isolates belonged to subgenotype A1, with the exception of two baseline isolates that belonged to genotype E and subgenotype D3, respectively. Various mutations were found in the 61 BCP/PreC region sequences (T1753C, A1762T G1764A, Kozak sequence, G1862T, G1896A) that could account for the high prevalence of HBeAg-negative infections observed at the various time-points. These mutations can lead to the down regulation of PreC mRNA transcription or translation, and/or affect post-translational modification of HBeAg. Amplification of the complete S-region and overlapping Polymerase regions yielded 47 sequences. Twenty-three of these sequences were from baseline samples, and the remaining from follow-up time-points. PreS deletions involved in the development of HCC were found in two follow-up isolates. These deletions, and other immune or detection escape mutations found in the S region, may contribute to the HBsAg negativity found in this study. In conclusion ALT levels and HBsAg status at baseline were predictors of the outcome of HBV suppression in response to anti-retroviral therapy. This study adds to the limited information available on the molecular changes observed in HBV isolates in HIV-infected South Africans under selection pressure from Lam.MT 201

A mixed method study of the relationship between HIV, mental health and human rights in the Socialist Republic of Vietnam

Evidence of the prevalence and impact of mental disorders on the HIV epidemic and on those it affects is lacking in low and middle income countries. Given the bulk of people living with HIV reside in low and middle income countries, understanding vulnerability to mental morbidity and barriers to the provision and uptake of mental health goods, facilities and services is required in these settings. To address this question, the study employed mixed methods to demonstrate the use of the human rights framework to describe and address the prevalence and impact of mental morbidity among men living with HIV in Vietnam. The Phan Vietnamese Psychiatric Scale and Harvard Trauma Questionnaire established that among a sample of 584 men in Vietnam, 18.7% had experienced depression over the last month while 6.2% suffered from post-traumatic stress disorder (PTSD). Risk of depressive disorder and PTSD were associated with more HIV related symptoms and cumulative exposure to stressful or potentially traumatic events. Using descriptive phenomenology, qualitative inquiries into the nature of the lived experience of mental illness among men living with HIV and their caregivers revealed that mental illness was salient, debilitating, and characterized by experiences of prejudice, exclusion, discrimination and brutal inequities. Both studies confirmed a compelling need for mental health care for men living with HIV and the lack of knowledge, skills and political will obstructing a response. Issues of risk and vulnerability to mental morbidity were described and linked to state neglect or denial of their human rights obligations. Building on the historical evidence of human rights as an effective public health strategy within the fields of HIV and mental health, the thesis concluded by applying a rights based approach to provide policy and programmatic responses to mental morbidity among men living with HIV. This involved examining the legal and policy environment under which policy and programs take place; systematically integrating core human rights principles, norms and standards, such as participation, non-discrimination, transparency, and accountability into policy and program responses; and focusing on key elements and normative content of the right to health

Treatment outcomes in patients infected with multidrug resistant tuberculosis and in patients with multidrug resistant tuberculosis coinfected with human immunodeficiency virus at Brewelskloof Hospital

Magister Pharmaceuticae - MPharmMany studies have reported low cure rates for multidrug-resistant tuberculosis (MDRTB) patients and MDR-TB patients co-infected with human immunodeficiency virus (HIV). However, little is known about the effect of HIV infection and antiretroviral therapy on the treatment outcomes of MDR-TB in South Africa. Therefore, the objectives of the study are: to find out whether HIV infection and interactions between ARVs and second line anti-TB drugs have an impact on the following MDR-TB treatment outcomes: cure rate and treatment failure at Brewelskloof Hospital. MDR-TB patients were treated for 18-24 months. The study was designed as a case-control retrospective study comparing MDR-TB treatment outcomes between HIV positive (cases) and HIV negative patients (controls). Patients were included in the study only if they complied with the following criteria: sensitivity to second line anti-TB drugs, MDR-TB infection, co-infection with HIV (for some of them), male and female patients, completion of treatment between 1 January 2006 and 31 December 2008. Any patients that presented with extreme drug-resistant tuberculosis (XDR-TB) were excluded from the study. Data were retrospectively collected from each patient’s medical records. There were a total of 336 patients of which 242 (72%) were MDR-TB patients and 94 (27.9%) MDRTB co-infected with HIV patients. Out of the 242 MDR-TB patients, 167 (69.2%) were males and 75 (30.7%) were females. Of the 94 patients with MDR-TB co-infected with HIV, 51 (54.2%) males and 43 (45.7%) females. Patients with multidrug-resistant tuberculosis co-infected with HIV who qualify for antiretroviral therapy were treated with stavudine, lamivudine and efavirenz while all MDR-TB patients were given kanamycin, ethionamide, ofloxacin, cycloserine and pyrazinamide. The cure rate of MDR-TB in HIV (+) patients and in HIV (-) patients is 34.5% and 30 % respectively. There is no significant difference between both artes (pvalue = 0.80). The MDR-TB cure rate in HIV (+) patients taking antiretroviral drugs and in HIV (+) patients without antiretroviral therapy is 35% and 33% respectively. The difference between both rates is not statistically significant. The study shows that 65 (28.0%) patients completed MDR-TB treatment but could not be classified as cured or failure, 29 (12.5%) patients failed, 76 (32.7%) defaulted, 18 (7.7%) were transferred out and 44 (18.9%) died. As far as treatment completed and defaulted is concerned, there is no significant statistical difference between HIV (+) and HIV (-) The number of patients who failed the MDR-TB treatment and who were transferred out is significantly higher in the HIV (-) group than in the HIV (+) group. Finally the number of MDR-TB patients who died is significantly higher in the HIV (+) group). The median (range) duration of antiretroviral therapy before starting anti-tuberculosis drugs is 10.5 (1-60) months. According to this study results, the MDR-TB treatment cure rate at Brewelkloof hospital is similar to the cure rate at the national level. The study also hows that HIV infection and antiretroviral drugs do not influence any influence on MDR-TB treatment outcomes.South Afric

Assessing treatment outcomes of people living with HIV on antiretroviral therapy at Kakamega County General Hospital in Kenya

Magister Public Health - MPHBackground: The goal of ART therapy is sustained viral load suppression with good immunological and clinical response. This optimal response to therapy results in the prevention of emergent ART drug-resistant mutations, decrease morbidity, and AIDS-related mortality and sustained retention on ART. Kenya, like most countries in Sub-Saharan Africa, has scaled-up the use of ART and is currently implementing a “Test and Treat” strategy in which any client identified and confirmed with an HIV diagnosis is initiated ART. Few studies have been carried out to ascertain the response of HIV patients initiating treatment in resource-limited settings. Moreover, it has been demonstrated that a certain proportion of patients fail to adequately respond to therapy and therefore require therapy modification. Aim: To assess treatment outcomes and calculate retention of HIV infected adult patients’ (15 years and above) initiating ART at Kakamega County General Hospital. The primary study outcome was the treatment outcome of patients-initiated ART two to three years prior to the study; while, the role of WHO criteria for screening treatment failure was assessed as a secondary outcome. Methods: This was a retrospective cohort study in which patients initiating ART between June 2014 and March 2015 were followed up until they were censored or study closed in August 2017. 284 patients were enrolled in the study after accurately matching information in their clinic files and the electronic medical record. Data were collected from patient records using a chart abstraction tool and transferred to an Access database from where the cleaning and validation of entries were done. Data from Access was transferred to STATA 15.1 for analysis. Descriptive statistics and inferential statistics were then performed to answer the research questions

Effects of Nonadherence to HIV/AIDS Drugs on HIV-Related Comorbidities in Eastern Nigeria

Developing countries like Nigeria continue to have HIV epidemic challenge due to the scarcity of evidence-based information and lack of resources to boost HIV education. The study population, Owerri, is one of the states in Nigeria with a high incidence rate of HIV. The purpose of this phenomenological study was to explore the experiences of people living with HIV/AIDS regarding the effects of nonadherence to HIV/AIDS drugs. The integrated theory of health behavior model provided the framework for the study. I collected, transcribed, and analyzed interview data to identify clusters and themes. Results showed that various factors influenced and (e.g., free drugs, fear, culture, medication side effects, discrimination, relationship/support system, poverty, belief, easy access) contributed to adherence behavior among respondents. People living with HIV/AIDS may be encouraged to adhere to drug treatments because of these research findings. This study contributed to a positive social change in that respondents were excited and open about sharing their fears, challenges, struggles and hope with the anticipation to influence others to be open about their HIV disease