The Association between Domestic Violence and Adherence to Antiretroviral Therapy in Southern India

Abstract

Background: An estimated 2.4 million HIV positive individuals reside in India; of whom approximately 485,000 are on antiretroviral therapy (ART). The Indian government provides public ART services throughout the country and this availability of ART has transformed HIV/AIDS from an acute life-threatening condition to a manageable chronic disease. However, to gain the clinical benefits of ART, strict adherence is necessary. Given this importance, simple and accurate measures of adherence are essential, and identifying barriers to achieving high adherence levels is key. The prevalence of domestic violence in India is high, but there is limited information about its association with adherence to ART. Objective: To identify the most appropriate self-report measure of adherence in the Indian context and assess the association between domestic violence and medication adherence among ART clinic attendees. Methods: We conducted a cross-sectional study of 246 HIV-positive individuals presenting for care at a Governmental ART clinic in Madras Medical College in Southern India. Data on socio-demographic characteristics, sexual behavior, HIV diagnosis, medications and experience of violence were collected through in-person interview. The AIDS Clinical Trial Group (ACTG) dose inquiry item, ACTG missed time inquiry item and the self-rating scale item (SRSI) self-report adherence to ART measures were administered. CD4 count at treatment initiation and most recent visit was abstracted from the medical records. Results: Overall self-report of ≥ 95% adherence was highest when measured using the ACTG dose inquiry (88.2%), followed by the ACTG time inquiry item (76.4%) and lowest with the SRSI measure (31.3%). Out of the three adherence to ART measures, the ACTG dose inquiry measure was the only measure that was significantly associated with change in CD4 cell count. There were no statistically significant differences between characteristics of individuals with ≥ 95% adherence and < 95% adherence as measured by the ACTG dose inquiry item. The prevalence of ever having experienced violence was 40% in the study population with gender differences in the association of experience of violence and adherence to ART. Women who experienced violence were 67% less likely to report ≥ 95% adherence to their ART medications (AOR=0.33, 95% CI 0.08-1.27). Conclusion: The ACTG dose inquiry measure was the most closely correlated with objective markers of adherence among HIV positive individuals in India. Exposure to violence may portend poor adherence to ART for women. Therefore routine screening of women for exposure to violence may be useful in clinical settings where HIV services are provided.