Adherence to antiretroviral therapy before and after substitution to Dolutegravir and associated factors among pregnant and postpartum mothers at the MUJHU supported facilities in Kampala - Uganda.

Abstract

Introduction: In 2020, the Uganda Ministry of health rolled out the use of dolutegravir based ART regimens as the preferred first line ART for all people living with HIV including the pregnant and postpartum mothers. Despite the proved efficacy and low toxicity profile of DTG, its introduction in Uganda faced great challenges with some women of reproductive age declining substitution to this regimen due to fear of teratogenicity. Although prior studies reported decline in ART adherence levels following regimen changes, there is no publicly available data on adherence following substitution to DTG based ART and factors associated with adherence to DTG in this population remain unknown. This study aimed to compare adherence to ART before and after substitution to dolutegravir based ART and associated factors among pregnant and postpartum mothers at Makerere University Johns Hopkins University research collaboration (MUJHU) and Kawempe ART clinics. Methods: A retrospective cohort design and a cross sectional study design were used to answer the study objectives. Facility records were reviewed for 506 participants to compare the adherence before and after ART change, to answer objective one. Exit interviews using a pretested standardized questionnaire were carried out for 342 participants to assess the factors associated with DTG based adherence, to answer objective 2. Qualitative data from 16 respondents were collected through in-depth interviews using an interview guide. Data were collected between 9th August and 9th September 2022. The Wilcoxon signed rank test was carried out on mean of the last three abstracted adherence data before changing to DTG and mean of the first three adherence levels following change to DTG based ART to compare adherence of the participants on these different regimens. To determine factors associated with DTG based ART adherence, bivariate and multivariable analysis were performed on quantitative data using the robust modified Poisson method while thematic analysis was used to analyze qualitative data. Results: There was a slight (2.1%) improvement in the mean adherence levels following the substitution of non-nucleoside reverse transcriptase inhibitor (NNRTIs) or protease inhibitors (PI) with DTG. 94% of the mothers had optimal adherence to DTG based ART. At multivariable analysis, the following factors had a statistically significant association with optimal adherence to DTG. Primary level education (aPR=1.13, [95%1.12, 1.96]), disclosure of one’s HIV status (aPR: 1.10 [1.04 – 1.19]) particularly to their spouses (aPR: 1.09 [1.04 – 1.19]) and not having experienced DTG related side effects (aPR: 1.09 [1.08 – 1.52]) were positively associated with optimal adherence while swallowing ART in the morning (aPR: 0.93 [0.87 – 0.95] had a negative association. These were supported with findings from the in depth interviews. Conclusion: Finding from this study show a 2.1% improvement in ART adherence among pregnant and postpartum women following their change to DTG based ART. However, the slight improvement seen is too small to confidently conclude that it was as a result of transitioning these mothers to DTG based ART since other time varying co variates were not catered for in this study. Additionally; the results seen could have been as a result of over powering the study due to the very large sample size used. 94% of the pregnant and postpartum women had optimal ART adherence and the key facilitators of optimal adherence to DTG included; disclosure of the spouse, level of maternal education, being free of ART side effects while swallowing of DTG based ART in the morning was identified as a barrier to adherence. Recommendation: Further studies with two comparable groups having similar characteristics are needed in order to cater for the time varying covariates and efficiently attribute the found improvement in adherence to transitioning to DTG based ART. With 94% of the mothers having optimal adherence, there is still need for clinicians to come up with innovate strategies to address the identified barriers in order to attain the UNAIDS goal of zero new HIV infections by 2030.