World Journal of AIDS, 2013, 3, 16-25 Published Online March 2013 (
Factors That Influence Anti-Retroviral Therapy
Adherence among Women in Lilongwe Urban Health
Centres, Malawi*
Noel Dzimnenani Mbirimtengerenji1, Getrude Jere1, Shyle Lengu2, Alfred Maluwa2
1Kamuzu College of Nursing, Lilongwe, Malawi; 2Kamuzu Central Hospital, Lilongwe, Malawi.
Received December 19th, 2012; revised February 16th, 2013; accepted February 28th, 2013
Introduction: Sub-Saharan Africa remains most severely affected, with nearly 1 in every 20 adults (4.9%) living with
HIV and this is accounting for 69% of the people worldwide. Although the regional prevalence of HIV infection is
nearly 25 times higher in sub-Saharan Africa than in Asia, almost 5 million people are living with HIV in South,
South-East and East Asia combined. Purpose: The purpose of this study was to find out the factors that influence
anti-retroviral therapy adherence among women in Lilongwe Urban, Malawi. Methods: A descriptive cross-sectional
design was used to study multi sites using quantitative methods. The sites were ART clinics at Area 18 health centre,
and Area 25 health centre. A questionnaire was used to a convenient sample of 118 HIV positive women. Quantitative
data from close-ended questions were coded and analyzed using the Statistical Package for Social Science (SPSS), ver-
sion 16. Logistic regression model was used to execute the potential covariates. Findings: ART adherence among
women is influenced by knowledge levels on: perceived importance and consequences for not adhering to ART; Short
waiting time; good relationships with the next of kin and service providers; trust and effective coping mechanisms to
stressful events. Source of information was highly associated with adherence in the logistic regression OR 2.89; CI (1.66 ±
5.38); p (0.039). Moreover, Short waiting time of the women at the hospital during the ARV refill period is highly asso-
ciated with ART adherence level OR 4.11; CI (2.05 ± 6.12); p (0.021). On the other hand, factors that contribute to
non-adherence are reduced knowledge level p-0.002; Side effects of ART; bad relationships with service providers and
relationship with the next of kin as well as occupation of the clients (women). Conclusion: Despite stressful events to
HIV positive living women, this study revealed that the majority of these participants would continue taking ART if the
factors are very minimal. Encouraging the women who stop taking ART particularly in urban health centres due to such
factors like religious beliefs that God is superior and will heal them would influence the ART survival rate in Malawi.
Keywords: ARV Adherence; Anti-Retroviral Therapy; Urban Health Centres
1. Introduction
AIDS is one of the greatest public health and social
problems threatening the human race in the world. The
greatest burden of the HIV/AIDS pandemic is in sub-
Saharan Africa. According to the Joint UN Committee on
HIV/AIDS [1,2], an estimated 36 million people world-
wide were living with HIV, of which 7 million were
newly infected [3,4]. Sub-Saharan Africa remains most
severely affected, with nearly 1 in every 20 adults (4.9%)
living with HIV and this is accounting for 69% of the
people that are living with HIV worldwide. Although the
regional prevalence of HIV infection is nearly 25 times
higher in sub-Saharan Africa than in Asia, almost 5 mil-
lion people are living with HIV in South, South-East and
East Asia combined. After sub-Saharan Africa, the re-
gions most heavily affected are the Caribbean and East-
ern Europe and Central Asia, where 1.0% of adults were
living with HIV in 2011.
Combination of ART, previously known as Highly Ac-
tive Antiretroviral Therapy (HAART) has dramatically
improved the survival of patients living with HIV &
AIDS in industrialized countries of the world, but the
availability of these ARVs in the developing countries is
still limited. Access to ART is an important element of
strategy to support people living with HIV and AIDS as
well as preventing transmission of infection [5]. By re-
ducing the viral load, ARV drugs may, reduce the risk of
HIV sexual transmission. Sick people can be able to re-
turn to work. Parents can stay alive longer, thus delaying
the time when children become orphans.
*Conflict of Interest: Non.
Copyright © 2013 SciRes. WJA
Factors That Influence Anti-Retroviral Therapy Adherence among Women
in Lilongwe Urban Health Centres, Malawi
In Malawi, at the beginning of 2004, there were nine
facilities in the public sector delivering ART, and esti-
mated 3000 - 4000 patients on treatment. In 2005, it was
estimated that 185,000 people were in immediate need of
ART. Because of this immediate need, a major scale up
of ART was planned. 60 hospitals and clinics in the pub-
lic sector were selected for ART scale up providing broad
geographical coverage throughout Malawi. Therefore,
more than 340,000 people were on treatment in 2008.
ART is provided free of charge in the public sector in
Malawi [5]. This Government controlled program is cur-
rently influencing people to seek for treatment of which
by 2012 all admitting hospitals and health centres, both
for the government and Mission facilities, were distrib-
uting the ARVs in the country.
Scale up in the new facility involved the use of first
line ART regimen only (Triomune-Stavudine, Lamivu-
dine and Nevirapine), but when health facilities showed
capacity to properly deliver such treatment, they were to
be provided with alternative first line and second line
therapy. A five-year plan for ART (2006-2010) was then
developed and approved by the MOH and its stake-
holders [6]. Malawi’s inspirational goal was to provide
universal access of ART by 2010 [6]. Fulfillment of this
goal means having 170,000 patients on treatment and
each year increasing this number of patients becoming
eligible for ART. i.e. (90,000 new patients per year).
2. Concept of Adherence
Dose adherence refers to the number and proportion of
doses taken; schedule adherence refers to adherence to
doses taken on time; and dietary adherence refers to
doses taken correctly with food [7]. Adherence and non-
adherence in Malawi is measured using various methods.
These include direct observation, blood drug concentra-
tion, electronic monitoring, pharmacy report, self-re-
porting 1 - 4 days, biomedical markers such as CD4+
count and viral level as well as adherence to clinical re-
port (White et al. 2008).
In Malawi more especially in urban health centres like
Kawale, Area 18 and Area 25 in Lilongwe city, adher-
ence is measured by pill count, pharmacy refill, not
missing appointments and reviewing the master cards of
patients. In this city where the HIV prevalence rate is
11.2%, adherence to ART is crucial. According to the
records of Kawale health centre [8], ART clinic, the total
number of patients accessing ART services from June
2005 to June 2010 was 2242. One thousand one hundred
and forty two (1142) clients out of the total number were
female non-pregnant, 260 clients were pregnant women
and 724 clients were males. This indicated that 63% of
females were accessing ART at this health centre and
47% males were accessing ART services. 980 (44%) cli-
ents out of the total number were adhering to ART and
1262 (66%) clients were not adhering to ART [9]. There-
fore, there was a need to find out factors contributing to
ART adherence and non-adherence among women in
Malawi. The significance of this study to the Malawi
nation was to determine the women adherence level
which would help to ensure viral suppression, decrease
the risk of disease progression and drug resistance.
Moreover, at Area 18 health centre in the same Li-
longwe City, the total number of clients enrolled for ART
from 2006 to March 2010 was 1150. Seven hundred and
eighteen (718) clients were females while 432 clients
were males. This then indicated that 62.4% females were
having the ARV and 47.6% males were also on therapy
[10]. Three hundred and thirty clients (330) had adverse
outcomes (died, defaulted, stopped and transferred out).
This data shows that there are more women accessing
ART than men and non-adherence and adherence were
not clear in this clinic. Therefore, there was need to find
out the factors contributing to this non-adherence and
adherence among the women.
Data from Area 25 health centre also indicated that
there are more female clients accessing ART than male
clients. According to the records from January to June
2010, 352 clients accessed ART services. Out the total
clients accessing ART services, 234 (66.5%) were fe-
males and the rest were males (43.5%) [10]. This can
also means that more females may adhere or non-adhere.
Limited studies had scientifically expounded those fac-
tors that influence adherence and non-adherence to ART
among women in Malawi.
The main objective of this study was to explore factors
that contribute to ART adherence and non-adherence
among women. For this to be done we came up with the
specific objectives that focused on assessing perceived
knowledge of ART adherence among women taking ART
in two of Lilongwe urban health centers. We also deter-
mined the modifying physiological factors contributing
to ART adherence and non-adherence among women
taking ART. We lastly also analyzed modifying psycho-
social factors contributing to ART adherence and non-
adherence among women taking ART.
These objectives were based on the following research
questions like; what were the level of knowledge on ART
adherence and non-adherence among women taking ART?
What modifying physiological factors contributed to
ART adherence and non-adherence among women on
ART in the urban areas? And we also questioned the
modifying psychosocial factors that contribute to ART
adherence and non-adherence among women on ART?
This research was based on Health Belief Model
which entails that women’s individual perception on HIV
Copyright © 2013 SciRes. WJA
Factors That Influence Anti-Retroviral Therapy Adherence among Women
in Lilongwe Urban Health Centres, Malawi
and AIDS is influenced by the physiological factors and
psycho-sociological factors. The women’s likelihood
action would be determined by the pandemic’s serious-
ness and perceived threats. The likelihood actions of
women like seeking medical care would be influenced by
social amenities that surround them like mass media HIV
programs, frequent radio HIV advertisements, television
comedies and close relative HIV infected serious illness
or death [11]. Furthermore, women particularly in Ma-
lawi, believe that perceived benefits of preventive action
must not outweigh the perceived barriers to preventive
health action.
3. Methodology
We used a descriptive cross-sectional quantitative design.
Descriptive study design was chosen as it is a means of
describing what exists in research. It also helps to deter-
mine the frequency with which something occurs. The
purpose of the descriptive research is the exploration and
description of the phenomena in real life situations
(Burns & Groove, 2005). In a cross-sectional study, the
information is collected from each subject at one point in
The setting for data collection was Lilongwe urban
health centres. Multi-sites were used which included,
Area 18 health centre, and Area 25 health centre. We
only focused on ART clinics to collect the data. These
areas were natural settings for women on ART as they
periodically go and seek advice on HIV positive living
and collect ARVs. Therefore, we did not manipulate the
setting of the study, so as to have a strong research valid-
ity and reliability. A convenient sample of 118 partici-
pants was used. In a convenient sampling, available sub-
jects were simply entered into the study until the desired
sample size was reached [12]. All clients who were reg-
istered at the clinics mentioned above and were on ART
participated in the study.
The inclusion criteria (see Figure 1) also involved
only women who were HIV positive and had come for
ART services at the clinics with more than three years on
therapy. These were only women who had been using
Area 18 and Area 25 health centres for their ART clinics.
Only women who were above 18 years of age and had
been registered in these clinics were involved. All clients
or women who were new at these clinics were not in-
volved in this study. Women who were on ART less than
three years were not included as they were considered
not to have more experience to determine the adherence
factors. Women who were transferred in the clinic from
other clinics although they were more than three years on
ART were excluded from participating in this study.
These inclusion and exclusion criteria were strictly fol-
lowed to reduce the selection bias and enhance the validity
Area 25 population
= 89019
m=718 TOTAL=1150
M=118 TOTAL=352
A-25 Sample
A-18 Sample:
Area 18 population
= 29045
Figure 1. Distribution of the sample size for Area 18 and
Area 25 health centres.
of the data.
Data was collected using a highly structured question-
naire with closed ended questions. Closed ended ques-
tions helped to provide direct quantitative unbiased data.
Such questionnaire elicited 100% response rate and had
an added advantage in their ability to produce no missing
data. The researchers interviewed the participants strictly
on face to face in avoidance of recall bias.
We strengthened the content validity of this study by
piloting the questionnaire in another area. So, data col-
lection tool was tested on similar participants at Mchinji
District Hospital, ART clinic which is more than 50
kilometers from Lilongwe city, but has the same Chewa
tribe of people. Moreover, we controlled a lot of con-
founders in this study by proper participants’ selection
and clearly matching the dependent and independent
variables [13]. Use of multivariate and logistic regression
intensified our confounding control.
We also sought permission from Lilongwe District
Health Officer who looks into the affairs of the selected
ART health centres which were, Area 18 and Area 25
health centres. Convenient sample of 118 participants
were assessed on factors contributing to ART adherence
and non-adherence from the two urban health centres in
Lilongwe.This means that samples were Area 18 (n = 51)
and Area 25 (n = 67). This sample size (n) was deter-
mined based on single population proportion (p) formula.
The following formula [14] was used:
Copyright © 2013 SciRes. WJA
Factors That Influence Anti-Retroviral Therapy Adherence among Women
in Lilongwe Urban Health Centres, Malawi
where n was sample size, p was the proportion of number
of HIV women in Lilongwe; and E2 was the margin error.
We only allowed 5% for expected margin of error (E)
with 95% confidence interval level. Z2 was used as a con-
stant value of 1.96.
Data was analyzed in order to summarize, organize,
interpret and numerically communicate the collected
information in inferential statistics. Quantitative data
from close-ended questions was coded and analyzed us-
ing the Statistical Package for Social Science (SPSS),
version 16. We generated tables that showed association
on p-value and positive odds ratio after using 95% as a
cut point in the bivariate analysis and logistic regression
models [15]. Some numerical data collected were pre-
sented in tables after comparing major variables in mul-
tivariate analysis.
Consent was sought from the participants before col-
lecting the data by proper explanation and signing their
initial names beside the data collector. In order to ensure
protection of human rights, clear explanation was done to
participants on the whole study; its purpose and benefits.
The participants were told about their rights to withdraw
from the study at any time they wish and that they would
not be punished for the decision made. Participants were
assured of confidentiality of the data collected, and that
no names were written on the questionnaire after inter-
view, instead numbers were used. They were also assured
of privacy to information given that the questionnaire
were kept in a locked cupboard and be accessed by the
researcher and the supervisor only. To minimize client’s
risks [16], the interviews were carried out for a maxi-
mum of 30 minutes. In addition to that, the questions
were asked in a way not to embarrass them nor coerce
the women.
4. Results
The results of this study shows that most women who
access ART are in the age ranging from 26 - 35 years
with a representation of 50% (59) = 118. This is followed
by those women aged 15 - 25 years 21% (17) = 118. This
strongly suggests that age is one of the contributing fac-
tors to ART adherence as only those women that were
above 26 - 35 could adhere properly to ART program.
The results also indicate that 49% (57.6) = 118 of women
accessing ART are of Chewa tribe since the data was
collected in the central region where most Chewa tribes
are found and is dominated by this tribe, this could not
have taken as a strong factor.
Most women accessing ART are married (63%). On
education background, the results indicate that most
women reached primary school (45.8%) followed by
those who reached secondary school (24.6%) and then
those who never attended school (22%). There was
strong association between the levels of education to the
adherence of the women on ART.
The results indicate that 48.3% of women earn a living
through business. However, the majority of women are
not employed, this puts them at risk to HIV and AIDS as
some women indulge into extra marital sex for money.
Only few women were found to rely on their husbands or
other people for financial support (22%). This is fol-
lowed by those who do small scale farming and sell their
crops to earn a living (17.8%). On next of kin, 49% of
women stay with their husband followed by 32.2% of
women who stay with their children alone or other rela-
tives and 11% of women either stay alone or with other
related members of their family. Hundred and eleven
participants (93.1%) reported of not smoking while 5.9%
of women reported of smoking cigarette. On alcohol con-
sumption, 105 (89%) of women do not drink alcohol
while 13 (11%) women consume different types of alco-
The data also shows that 47.5% of women who access
ART have adequate knowledge that ART can be started
to be taken when the immunity is low while the rest
(52%) have no adequate knowledge on when to start ART.
When asked about the source of information, about ART,
91.5% of the participants answered that they got the in-
formation from the medical personnel. The rest got the
information from friends (2.5%) and through the mass
media (5.1%). This suggests that most of the people get
the information from the health care personnel.
When asked about the knowledge level on adherence,
83.1% of women answered correctly that it means taking
drugs at the right time as prescribed by the ART service
provider. This suggests that ART non adherence could
not be caused by inadequate knowledge level of the cli-
ents. However, 12.7% only concentrated on not becom-
ing sick anyhow as the main factor. The rest (4.2%) con-
centrated only on prevention of resistance to ART as the
cause of non adherence factor.
When asked whether they adhere to ART or not, 107
(90.7%) women said they adhere to ART while 11 (9.3%)
women admitted of not adhering to ART. When asked
about how they know that they adhere i.e. indications
that they adhere to ART, 24.6% of women measure ad-
herence by pill count, 35.6% measure by not becoming
sick more often. On the other hand, 22.7% of participants
measure by finishing all the drugs before they go for re-
fill while 15.3% of women measure adherence by fulfill-
ing appointments. Only 2.5% of participants measure
adherence by CD4 count. This suggests that most of the
clients do not know the effective way of adherence.
On indications of non-adherence, it was noted that
45.8% of the women measure it by frequent illnesses
while 22% measure adherence by pill count. On the other
Copyright © 2013 SciRes. WJA
Factors That Influence Anti-Retroviral Therapy Adherence among Women
in Lilongwe Urban Health Centres, Malawi
hand, 14.4% of the participants measure non-adherence
by skipping days without taking drugs and missing ap-
pointments. However, 9.6% don’t understand how to
know that they are not adhering to ART. Therefore, it was
noted that frequent illness especially the ARV side effects
is the major parameter for women’s ART adherence.
It was also noted that Christians were mostly adhering
to ART (89.6%) than other denominations. In this analy-
sis selection bias could not be controlled as a result being
a Christian did not show much significant to the adher-
ence. This is because the study setting was dominated by
the Christians.
However, it was noted that level of education is a
strong factor to adherence of the ARV for women in Li-
longwe as the bivariate analysis showed a p-value of
0.004 (p < 0.05) at 95% confidence interval.
Furthermore, the next of kin for the women who were
on ARV showed the p-value of 0.051 in a bivariate
analysis using Pearson Correlation Coefficient. This
suggests that women’s adherence to ARV is influenced
by the type of the next of kin. These people indeed could
help keep reminding the women on the need for refill at
the clinic or getting treatment for the ARV side effects.
Table 1 also shows the relationship between knowl-
edge and adherence/non-adherence to ART. It was noted
that women who also use the immune boosters are ad-
hering to ART effectively 96.4% (54) than those not us-
ing the boosters. This suggests that these women per-
ceive the importance and benefits of using the ART and
are having positive outcome. Moreover, the women who
adhered to ART had adequate knowledge that these drug
are taken for life.
Table 2 reveals that almost all participants of different
age ranges (82.2%) said that their general health status
improved after ART initiation. However, some partici-
pants (17.8%) did not see any improvement. This was
due to the time they started ART that it was short for
them to notice any improvement or due to side effects
experienced in the course of taking ART.
Participants who were stable in marriage (98.3%) ex-
perienced an improvement in their general health status
after taking the ARVs for more than three years. However,
those women who reported of not improved much are the
ones who got divorced (27.8%) which is the highest
number to show that they did not improve.
A remarkable increase in the education was also seen
in those who went to primary (97.9%, n = 47) and sec-
ondary (100%, n = 26) schools. These participants noted
their health status improving. It also indicated that
women who are educated up to the secondary level could
perceive health status improvement while taking the
ARVs. On the other hand, 33.3% of participants who
never attended school did not see any improvement.
Table 1. Relationship of art adherence and perceived know-
ledge n = 118.
Variables Do you
adhere to art?
Knowledge level Values Yes No P-Value
Married 58 6
Single 14 1
Divorced 16 2
Separated 58 6
Marital status
Widowed 5 0
Christian 78 9
Muslim 21 1
Other 8 1
Never attended 20 6
Primary 51 3
Secondary 28 1
Level of education
College/university 8 1
Parents 8 1
Husband 54 4
Children 35 3
Others 10 3
Next of kin
Parents 8 1
Lifelong drugs 51 9
Immunity boosters 54 2
ART knowledge
Not sure 2 0
Hospital 97 11
Friends 3 0
Source of information
Radio 7 0
prescription 88 10
You don’t become
sick anyhow 15 0
Prevents drug
resistance 4 1
When pills remain <8 27 2
When not sick
more often 40 2
When CD4 is <250 3 0
When no pills remain 24 2
knowledge time
When I fulfill
appointments 13 5
When pills remain >8 25 1
When CD4 < 250 12 0
When I skip days
without taking drugs 13 4
Frequent illnesses 48 6
knowledge time
Don’t know 9 0
Copyright © 2013 SciRes. WJA
Factors That Influence Anti-Retroviral Therapy Adherence among Women
in Lilongwe Urban Health Centres, Malawi
Copyright © 2013 SciRes. WJA
Table 2. Relationship of general health status and demographic variables n = 118.
General health status since art initiation?
Demographic data Co-Variates Improved P-Value Not improved P-Value Total
15 - 25 yrs 21 91.3% 2 8.7% 23 100%
26 - 35 yrs 44 95.7% 2 4.3% 46 100%
36 - 45 yrs 20 95.2% 1 4.8% 21 100%
46 - 55 yrs 8 72.7% 3 27.3% 11 100%
56 - 65 yrs 4 66.7%
2 31.3%
6 100%
Chewa 38 90.5% 4 9.5% 42 100%
Tumbuka 12 85.7% 2 14.3% 14 100%
Yao 15 100% 0 0.0% 15 100%
Ngoni 18 81.8% 4 18.2% 22 100%
Other 14 100%
0 .0%
14 100%
Married 58 98.3% 1 1.7% 59 100%
Single 14 100% 0 0.0% 14 100%
Divorced 13 72.2% 5 27.8% 18 100%
Separated 11 78.6% 3 21.4% 14 100%
Marital status
Widowed 1 50%
1 50%
2 100%
Christian 70 89.7% 8 10.7% 78 100%
Muslim 20 100% 0 0.0% 20 100%
Other 7 77.8%
2 22.2%
9 100%
Never attended 16 66.7% 8 33.3% 24 100%
Primary 47 97.9% 1 2.1% 48 100%
Secondary 26 100% 0 0.0% 26 100%
Level of education
College/university 8 88.9%
1 11.1%
9 100%
Business 50 94.3% 3 5.7% 53 100%
Teacher 9 100% 0 0.0% 9 100%
Medical personnel 3 75%
1 25%
4 100%
Therefore, education was perceived as a major factor
for ART adherence and it matters more for women’s
health on ART.
It was also revealed that those women who do business
adhere to ART more than those with different occupa-
tions. This is so because they are self-governed on the
time they are to go for refill as compared to those who
are employed by other people or are not working. If these
people have high adherence rates, then they have ade-
quate knowledge on adherence.
When bivariate analysis was used in the analysis, we
could not reject the null hypothesis that women who de-
pended on the hospital as source of information were
associated with the ART adherence, the p-value of the
two tailed t-test was 0.002 (p < 0.05) at 95% confidence
It was also noted that peripheral neuropathy is the
commonest side effect for those women who are adher-
ing to the ART (see Table 2). But most of the women had
been experiencing such side effects at the beginning of
the ART. However, we rejected the null hypothesis that
peripheral neuropathy is associated with ART adherence
Factors That Influence Anti-Retroviral Therapy Adherence among Women
in Lilongwe Urban Health Centres, Malawi
as the two tailed t-test was 0.234 (p < 0.05).
It was also found out that marital status is highly asso-
ciated with women’s health status on ARV, p-value was
0.016 (p < 0.05). This suggests that women who were
married were effectively motivated to continue treatment
by their spouses. Furthermore in Table 2, level of educa-
tion was highly associated with the general health status
of the women on ART as the two tailed t-test revealed
p-value of 0.004 (p < 0.05).
We could not also reject the null hypothesis that type
of occupation is strongly associated with the women’s
general health status on ART as the two tailed t-test
showed p-value of 0.001 (p < 0.05).
In the logistic regression Table 3 above, the mean of
summative knowledge variables 56.9 was used as the cut
point for the construction of the model. Different ordinal
variables were executed into the model to associate with
the women’s general health status as the independent
ordinal variable at 95% confidence internal and a predic-
tive alpha level of 0.05.
Use of lifelong drug by women on ARV was found to
be high associated with general health status in the logis-
tic regression model as the OR 3.49; CI (1.59 ± 6.36);
p (0.001) (see Table 3). This means that women who had
had a chance to take lifelong drugs before found it easy
to follow the instruction of the ARV when initiated as
they had been using other drugs before thereby their
health improved tremendously.
It should also be pointed out that women’s source of
health, on related information from the hospital was
highly associated with their general health status since
the OR 2.89; CI (1.66 ± 5.38); p (0.039). This indicates
that availability of health related information to women
at the hospital helps to make their general health status to
improve. Therefore, source of information is a strong
factor that influence ARV adherence.
When covariate “following prescription” was executed
into the logistic regression in Table 3, it was highly as-
sociated with women’s health status as the OR 2.67; CI
(1.54 ± 4.66); p (0.028). This means that all women who
were following the prescription of the ARV improved
their general health status greatly. So, following prescrip-
tion has been found to be a strong factor that influence
ARV adherence.
Table 3. Logistic regression of women’s general health status with their art knowledge level on HIV/AIDS n = 118.
Women’s general health status
Women’s knowledge level Co-Variables Improved Not improved Odds ratio CI (95%) P-Value
ART knowledge Lifelong drugs 46 85.2%8 14.8% 3.49 1.59 - 6.360.001
Immunity boosters 50 98% 1 2% 1.47 0.50 - 4.270.476
Not sure 1 50% 1 50% - - -
Hospital 89 90.8%9 9.2% 2.89 1.66 - 5.380.039
Friends 2 100% 0 0.0% 0.35 0.15 - 0.800.014
Source of information
Radio 6 85.7% 1 14.3% - - -
Following prescription 82 92.1%1 7.1% 2.67 1.54 - 4.660.028
You don’t become sick anyhow12 85.7%2 14.3% 1.09 0.68 - 2.550.393
Adherence knowledge
Prevents drug resistance 3 75% 1 25% - - -
Yes 88 91.7%8 8.3% 6.22 1.98 - 7.310.002
Adhere to ART No 9 81.8% 2 18.2% - - -
When pills remain <8 24 100%0 0.0% 3.41 1.36 - 5.920.001
When not sick more often 34 90.2%4 9.8% 0.48 0.10 - 0.780.762
When CD4 is <250 2 66.7% 1 33.3% 3.39 1.22 - 3.810.031
When no pills remain 21 87.5%3 12.5% 0.58 0.11 - 0.640.567
Adherence knowledge time
When I fulfill appointments 13 86.7%4 13.3% - - -
When pills remain >8 18 100%0 0.0% 5.31 1.11 - 3.700.034
When CD4 < 250 10 90.9%1 9.1% 6.19 1.37 - 2.330.027
When I skip days
without taking drugs 14 87.5%2 12.5% 0.29 0.17 - 0.890.663
Frequent illnesses 49 92.5%4 7.5% 0.81 0.36 - 0.980.788
Non-Adherence knowledge time
Don’t know 6 66.7% 3 33.3% - - -
This is a logistic model generated after using 95% cut point for the regression formula.
Copyright © 2013 SciRes. WJA
Factors That Influence Anti-Retroviral Therapy Adherence among Women
in Lilongwe Urban Health Centres, Malawi
Hospital waiting time (see Table 3) was also found to
be at board line relationship with ARV adherence as the
p-value was 0.052. This means that the more the waiting
time the less likely the women’s ARV adherence (see
Table 4).
Short waiting time of the women at the hospital during
Table 4. The relationship between women’s appointment time and ARV side effects n = 118.
Appointed time fulfillment
Variables Covariates No Yes P-Value
Time for work/business 9 2
Transport problems 15 1
Distance 3 1
Illness 7 1
< hour 9 33
2 hours 10 25
3 hours 7 8
4 hours 4 11
Hospital waiting time
5 hours & more 5 6
They encourage 14 29
They discriminate 1 3
Relationship with next of kin
They don’t care 20 47
Husband 12 23
Children 1 8
Sisters/ brothers 2 4
Other related members on ART
Other 10 28
Ashamed of self 2 7
A sinner 4 4
Tired 5 2
Feelings when taking the drug at home
Good 24 70
1 - 6 m ago 8 20
6 - 12 m ago 16 30
2 - 5 yrs ago 8 28
Initiation ART period
6 - 10 yrs ago 3 5
Nausea/vomiting 4 13
Jaundice 3 1
Peripheral neuropathy 14 12
Rash 2 8
ART side effects
Nothing 12 49
At the beginning 9 19
Not often 13 11
Very often 3 6
Experienced length of side effects
Daily 0 2
Weight gain 19 35
Weight loss 1 6
Chronic rash 5 5
Lipodystrophy 3 1
Physiological ART side effects
Other 7 20
Improved 26 80
General body status
since the initiation of ART Not improved 9 2 0.049
his is a bivariate analysis table with.
Copyright © 2013 SciRes. WJA
Factors That Influence Anti-Retroviral Therapy Adherence among Women
in Lilongwe Urban Health Centres, Malawi
the ARV refill period is highly associated with adherence
level OR 4.11; CI (2.05 ± 6.12); p (0.021). This means
that when the women go to the clinic and are seen imme-
diately, could influence them to come back during the
next visit without hesitation as a result this influence
them to ARV adherence throughout their life.
Furthermore, strong religious beliefs that God has su-
pernatural powers and heals HIV and AIDS has been
found to be strongly associated with non adherence to
ARV among women in Malawi OR 5.37; CI (3.16 ±
7.36); p (0.004). This is a pathetic situation to most
women who are strong believers. Women even stop tak-
ing the ARV once they have been offered a prayer by a
local Christian prophet.
Moreover, in table four, fulfilling of appointment was
also related to general body status. Those who felt not
improved could not meet the appointment but those who
felt that they were improving met the appointment as the
p-value was found to be 0.049 (p < 0.05).
The study has revealed that common the main factors
that influence adherence are women’s side effects that are
experienced in the course of taking ART which are nau-
sea and vomiting, generalized rash and peripheral neu-
ropathy. This is similar to the study done by the British
Columbia [17], that found out that the effects of ART
included, skin rash, nausea and vomiting among others.
The study discovered that those who experienced side
effects just at the beginning of ART initiations adhered to
ART as compared to those who experienced side effects
very often that they found it difficult to adhere to ART.
Lipodystrophy and weight loss are also some of the
factors noted in this study of which some of the women
on ART developed and were causing them not to take the
ARVs continuously [17]. These side effects distort their
body image that they feel anyone may know that they are
on ART and these make them stop adhering to ART. This
is in relation to what Reynolds [18] discovered. The
study discovered that participants who had lipodystrophy
and fat loss as side effects engaged in harmful behaviours
in order to control bodily changes. Reynolds [19] also
noted that participants feared that weight loss represented
disease and worried that visible changes would lead to
unintentional disclosure of their HIV status.
The study also revealed that most individuals who fail
to fulfill appointments because of traveling long dis-
tances to collect ARVs and the majority goes by walking
which is tiresome. The findings are similar to what An-
nelie et al. [20] discovered. Annelie’s study found out
that financial struggles with ART related costs like
transport, food, hindered adherence to ART of which this
has been true in this study. The study also found that pa-
tients who stayed on the queue for a long time (4 - 5
hours and more) before being helped by the service pro-
vider found it difficult to fulfill all appointments as they
were thinking of the past experiences encountered at the
same health centre [21]. This also makes ART users who
also work to not visit the clinic for refill at the appointed
The study further revealed that most clients have good
relationships with their next of kin and with their service
providers that they both encourage and help them ac-
cordingly. This helps them get relieved from anxiety and
make them feel at home and needed. This is in contradic-
tion to what Klitzman et al. [22,23] discovered that if
family members or friends see patients to be taking ART;
this conveys a signal that they are HIV positive or living
with AIDS. Despite stressful events, the study found out
that the majority continue taking ART. This indicates
effective coping mechanisms for the women on the ART
[24,25]. On the other hand, some participants stopped
taking ART reasoning that God is superior and will heal
them (relies for God’s interventions) [26]. Indeed some
respondents believed in spiritual healing and abandoned
ART in this study which is not good as this could only
aggravate or the HIV in the body.
5. Conclusion
The study has found out that the main factors that con-
tribute to ART adherence among women are increased
knowledge levels on adherence, its importance and con-
sequences for not adhering to ART; Short waiting time;
good relationships with the next of kin and service pro-
viders; trust and effective coping mechanisms to stressful
events. On the other factors that contribute to non-ad-
herence are reduced knowledge level; Side effects of
ART; bad relationships with service providers and with
the next of kin as well as occupation of the clients. De-
spite stressful events to HIV positive living women, this
study revealed that the majority of these participants
would continue taking ART if the factors are very mini-
mal. Encouraging the women who stop taking ART par-
ticularly in urban health centres due to such factors like
religious beliefs that God is superior and will heal them
would influence the ART survival rate in Malawi.
6. Recommendation
There is need to review the policy and evaluate their pre-
vious policy on HIV and ART thereby adding some in-
formation with the aim of addressing the problems iden-
tified in this study. There is need to improve service pro-
viders relationship with clients this will help to identify
their problems in the course of rendering care to client
who are on ART. The researcher recommends that ART
service providers should be starting as earlier as possible
to assist clients so as to minimize waiting time by the
Copyright © 2013 SciRes. WJA
Factors That Influence Anti-Retroviral Therapy Adherence among Women
in Lilongwe Urban Health Centres, Malawi
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