“Stigma, Poverty, and Drugs” Social Barriers Preventing Adherence to Comprehensive HIV Therapy in Guatemala

Abstract

Background: Since diagnosis of the first case in 1981, HIV has become one of the most destructive pandemics in history already having killed 36 million persons. While the development of medical therapy has significantly reduced death rates, many populations around the world still face obstacles that impede them from accessing treatment. Many studies have examined adherence to treatment but few have focused on patients’ comprehensive engagement in services and potential obstacles associated with adherence. The objective of this thesis is to examine the barriers to treatment adherence and better understand the societal context of HIV in Guatemala. Methods: In order to understand the complexities surrounding treatment adherence and the social barriers to compliance in Guatemala, a mixed methods approach was used that included in-depth interviews with eighty-two patients at la Clínica Familiar ‘ Luis Angel Garcia’ (CFLAG) in Guatemala City, and the usage of medical records from the clinics’ database. After receiving written consent, patients were asked about their demographics, experience at the clinic, and obstacles that challenged their compliance in terms of making appointments and/or taking medication. Responses were analyzed and interpreted both qualitatively and with statistical testing for significance and association. Using the statistical program R, testing was conducted in order to examine the relationship between specific patient characteristics and adherence. Qualitative results were used in formulating policy recommendations for the clinic. Results: Using specific criteria for determining adherence among patients: a) appointment attendance; b) viral load; c) immune cell defenses; and d) consumption of ARVs), 48% (N=37) of patients were classified as in-adherent by at least one criterion. 35% (N=13) of in-adherent patients were classified based on appointment attendance, 35% (N=13%) based on viral load, 62% (N=23) based on immune cell defenses, and 8% (N=3) based on consumption of ARVs. Statistical testing showed that patients’ inflexible work schedules, enrollment in school, and heavy pill burden were associated with inadherence. In addition, co-infections, drug use, and place of residence were also significantly correlated. Qualitative results showed that while the majority of patients were very comfortable with CFLAG staff, substantial proportions preferred to meet with the same physician or psychologist at each appointment. In addition, patient testimonies reinforced quantitative results and emphasized financial instability and stigma as maybe barriers to treatment among patients. Conclusions: Based on patient narratives, statistical testing, and HIV literature, it is evident that inflexible work schedules, discrimination, marginalization of Indigenous groups, and drug use are correlated with in-adherence. Based on these associations and suggestions given by patients, it is recommended that the clinic consider implementing same-physician/ psychologist appointments for patients interested as well as the automated reminder system. It is highly recommended that Latin America as a region focuses on increasing HIV testing and constructing treatment cascades for policy focus. Lastly, because discrimination remains ubiquitous, the Guatemalan government needs to focus on enforcement of Law 317 and protection of PLWHA’s human rights.