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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 1  |  Page : 49-54

Challenges of Accessing Care in Art Clinic during COVID-19 Lockdown in Lagos


1 Department of Clinical Sciences, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
2 Department of Clinical Sciences, Nigerian Institute of Medical Research, Yaba, Lagos State; Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria

Date of Submission25-Jun-2020
Date of Acceptance23-Nov-2021
Date of Web Publication19-Jan-2022

Correspondence Address:
Dr. O O Odubela
6 Edmond Crescent Yaba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_391_20

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   Abstract 


Background: As the SARS-CoV-2 pandemic continues to ravage the world, its impact on the health systems and survival of people with chronic diseases especially People living with HIV [PLWH] could be undermined. It becomes relevant to assess the challenges PLWH face during this period to institute measures towards combating the negative effects of the pandemic. Aims: This study aims to investigate the challenges faced by PLWH in accessing care during the lockdown period in Lagos, Nigeria. The study was a cross-sectional one involving PLWH aged 18 years and above who presented for care. An interviewer-administered questionnaire was used to obtain information on demographic characteristics, their knowledge about COVID-19 disease, and challenges experienced in accessing care during the COVID-19-induced lockdown. Ethical approval was obtained from the Institution Research Ethics Board (IRB) of NIMR. Patients and Methods: Data generated from the survey was exported to Excel and analyzed using SPSS version 23.0. Results: The mean age of PLWH who participated in the study was 42.2 (±12.2) years. The majority were female (74.3%), married (66.3%), employed (58.9%), and on less than $100 monthly income (80.5%). The commonest challenges experienced were psychological (78.5%), financial (68%) and food (40.7%). There were significant association among the income status, lack of food (OR: 2.5, CI: 1.4-4.5, P = 0.002), financial challenges (OR: 1.7, CI: 1.0-3.0, P = 0.048) and psychological challenges (OR; 1.8, CI: 1.0-3.5, P = 0.05). Ninety-five percent of participants believed SARS-COV-2 infection is a viral infection. Conclusions: PLWH faces a myriad of challenges that would have a significant impact on their overall well-being and the gains of HIV care.

Keywords: Access, care, challenges, COVID-19, HIV, Nigeria, SARS-CoV-2


How to cite this article:
Salako A O, Odubela O O, Ohwodo H O, Opaneye B, Ojuko S O, Nwankwo N L, Ejiga Q E, David A N, Ezechi O C, Salako B L. Challenges of Accessing Care in Art Clinic during COVID-19 Lockdown in Lagos. Niger J Clin Pract 2022;25:49-54

How to cite this URL:
Salako A O, Odubela O O, Ohwodo H O, Opaneye B, Ojuko S O, Nwankwo N L, Ejiga Q E, David A N, Ezechi O C, Salako B L. Challenges of Accessing Care in Art Clinic during COVID-19 Lockdown in Lagos. Niger J Clin Pract [serial online] 2022 [cited 2022 Nov 30];25:49-54. Available from: https://www.njcponline.com/text.asp?2022/25/1/49/335981




   Introduction Top


The human immunodeficiency virus (HIV) infection remains a public health threat and a significant cause of morbidity and mortality especially in Sub-Saharan Africa despite the availability of life-saving antiretroviral therapy (ART).[1] In 2018, 1.9 million Nigerians were living with HIV and 53,000 people died from the infection.[2] While access to ART nearly tripled from 2010 to 2018, [from 360 000 people in 2010 to more than 1 million people in 2018] there has only been a 26% decrease in annual mortality during the same period. Current data indicate that more than 50% of people living with HIV on ART have unsuppressed viral loads.[3]

ART functions by suppressing viral replication, facilitating immune reconstitution, and preventing viral transmission and development of resistant strains, thereby reducing morbidity and mortality and improving the quality of life among infected persons.[4] However, all these functions are dependent on at least 95% adherence to the antiretroviral regimen.[3],[4] Poor adherence to ART is significantly associated with poor treatment outcomes. Factors associated with poor adherence to ART include being single, unemployed, and using alcohol, whereas reasons for nonadherence ranged from forgetfulness, being away from home, difficulty getting to the care centre to collect drugs, being too busy, and drug side-effects.[5],[6],[7],[8]

While adherence to antiretroviral therapy is one of the primary determinants of treatment outcome, adherence to other care regimens such as keeping doctor appointments and ensuring scheduled laboratory tests are equally important. These are crucial for patient monitoring, and help to ensure that the patient is placed on the best care for their dynamics.

In order not to lose the gains made in the fight against HIV over the years, every effort must be deployed to ensure that HIV-infected persons are started on ART and retained in care with a target of achieving suppressed viral load. The UNAIDS 90-90-90 strategy (now 95-95-95 by 2030) addresses this need.[9] Another strategy is the test and treat strategy, which was adopted by the Federal Government of Nigeria in 2016.[10] Other modalities are the differentiated models of care, which include the multi-month scripting and dispensing, and involvement of community pharmacies and peer volunteers in the dispensing and distribution of antiretroviral drugs to people living with HIV (PLWH).[11]

All the above strategies depend on a functional health system and the ability of PLWH to access the care they need from health facilities. Access to care can be hampered by several factors including availability of health facilities and requisite healthcare workers, distance of the health facility, transportation costs and cost of drugs/laboratory tests, long waiting times, attitude of healthcare workers, and stigma and discrimination.[12],[13]

The novel coronavirus disease 2019 (COVID-19), first detected in China in December 2019, has spread to 216 countries and territories with 6,881,352 confirmed cases and 399,695 deaths globally as of June 8, 2020.[14],[15] The disease is a respiratory droplet infection with a high infectivity rate. This has caused several nations across the globe to adopt public health measures ranging from improved hand hygiene and face masking to complete movement restrictions otherwise known as lockdowns in an effort to contain the spread of the disease.

The first case of COVID-19 in Nigeria was identified in February 2020 and on March 31, 2020, the Federal Government of Nigeria instituted a total “lockdown” in the most affected states: Lagos, Ogun, and the Federal Capital Territory, Abuja. Only essential workers like health and security personnel and vehicles carrying essential supplies like food and petroleum products were allowed free passage. Public transportation was supposed to be grounded to a halt, but some operators continued clandestine activities at extortionate prices; the total lockdown lasted for one month, with a gradual easing of the lockdown commencing in May 2020.

The lockdown created significant disruption in the economic, social, and spiritual lives of the populace. Its effect on patients with chronic diseases on long-term medication and regular clinical follow-up, who may not be able to keep their clinic appointments or access their drugs is yet to be determined. In the case of PLWH, the inability to pick their drugs will engender nonadherence with its multiplier effects of viral rebound, immune suppression, increased morbidity and mortality as well as increased transmission of infection, thereby reversing the gains made over the years in the fight against the HIV pandemic.

The challenges faced by people living with HIV (PLWH) in trying to access care and treatment for their illness during this period needs to be evaluated. The findings will contribute to policy formulation on the movement of persons with chronic ailments during future lockdowns. This study aims to investigate the challenges faced by PLWH in accessing HIV treatment and care during the COVID-19 lockdown period in Lagos, Nigeria.


   Patients and Methods Top


Study design and setting

This cross-sectional study was carried out at the HIV Outpatient Clinic of the Clinical Sciences Department (CSD), Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria. The centre has provided comprehensive HIV care and treatment services to over 25,000 adults, pregnant women, adolescents, and children living with HIV since inception in 2002.

Study population

The study participants were consenting adult PLWH, aged 18 years and above, who have been on HIV care for at least 6 months and presented for care at the clinic during the one-month movement restriction, otherwise known as “lockdown”.

Study instrument

A pretested interviewer-administered questionnaire was used to obtain information on demographic characteristics, HIV-related characteristics, knowledge of COVID-19, and challenges experienced in accessing care during the COVID-19-induced lockdown.

Data analysis

Data generated from the survey were entered into an Excel spreadsheet, cleaned, and then exported to SPSS for analysis with SPSS version 23. Student's t-test and ANOVA was used for analysis of continuous variables while the Chi-Square test was used for categorical variables. Results are presented as tables and charts.

Ethical considerations

Ethical approval was obtained from the Institutional Review Board (IRB) of NIMR (IRB/20/031). Patients were fully informed about the study and its processes; confidentiality was ensured and informed consent signed before the commencement of the study.


   Results Top


Of the 365 PLWH eligible to participate in the study during the period, 344 participants consented to be part of the study, giving a 94.2% response rate. The mean age of respondents was 42.2 ± 12.2 years, with the predominant age group being 41-50 years (41.4%). The majority were female (74.3%), married (66.3%), employed (58.9%), and on less than $100.00 monthly income (80.5%). Most of the participants had disclosed their HIV status to their partners (84.9%) and had at least one-month stock of antiretroviral drugs (ARVs) at home (68.7%) [Table 1].
Table 1: Socio-demographic characteristics of study participants

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A significant proportion of study participants were residents of Lagos State with Surulere (12.8%), Alimosho (12.1%), Oshodi-Isolo (11%), Kosofe (11%), and Mainland (6.7%) local government areas [LGA] accounting for the majority [Figure 1]. These LGAs were approximately 9.49 (±4.8) km from the study facility and most of the participants accessed the care center by walking (36.2%), public transport (34.7%), and private vehicles (29.1%) [Table 2].
Figure 1: Number and distance from different LGAs

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Table 2: Means of getting to NIMR by respondents

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With respect to challenges faced, the participants experienced psychological (270/344), financial (234/344), and food security (140/344) challenges. The commonest psychological challenge experience included fear (60), depression (20%), and anxiety (16%) [Table 3]. The supports required to pull through the lockdown period includes financial (56%), treatment support (24.4%), and food security (9.6%). In addition, only 4.1% of the study population had received support from non-governmental organizations or the government. A majority of respondents (255) had at least three (3) challenges during the lock down period as against very few (17) having 6 or more challenges concurrently during the same period [Figure 2].
Figure 2: Frequency of physical challenges among respondents

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Table 3: Challenges faced by respondents*

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There were no significant association between duration of ART use and challenges evaluated [(financial; OR: 1.1 CI: 0.7-1.7 P = 0.74), (lack of food; OR: 1.4, CI: 0.9-2.2, P = 0.15), (transport; OR: 1.4 CI: 0.9-2.2, P = 0.18), (electricity; OR: 1.3, CI: 0.8-2.2, P = 0.22)] except psychological challenges experienced (OR; 2.1 CI: 1.2-3.8, P = 0.01).

There were no significant association between disclosure status and the various challenges; financial (OR; 1.2 CI: 0.6-2.2, P = 0.67), psychological (OR; 1.7, CI: 0.7-4.3, P = 0.23), lack of food (OR; 1.1 CI: 0.6-2.1, P = 0.69), transport (OR; 1.0 CI: 0.6-0.9, P = 0.90), and electricity (OR: 1.0 CI: 0.5-2.0, P = 0.97).

Furthermore, there was no significant association between the income status and the challenges such as transport (OR: 1.0, CI: 0.6-1.8, P = 0.84) and electricity (OR: 1.4, CI: 0.8-2.5, P = 0.20), although there was a significant association between the income status, lack of food (OR: 2.5, CI: 1.4-4.5, P = 0.002), financial challenges (OR: 1.7, CI: 1.0-3.0, P = 0.048), and psychological challenges (OR; 1.8, CI: 1.0-3.5, P = 0.05).

Majority of the study participants (326/344) believed that SARs-COV-2 infection exists with (209/344), (54/344) of them attributing it to viral infection and consumption of exotic/strange animals, respectively.


   Discussion Top


The lockdown measures induced by the SARS-CoV-2 pandemic to limit the community transmission have created significant disruption in the economic, social, and spiritual lives of the populace. The impact on HIV patients assessing care and treatment for their illness needs to be evaluated in this current period. This is to help mitigate against challenges encountered now to create a template against future similar occurrences and to ensure the sustained gains of the HIV care towards the UNAIDS 95-95-95 strategy.

The current study describes the challenges PLWH encounters during the COVID-19 pandemic-induced movement restriction. The mean age of the participants was 42.2 (±12.2) years, with a majority of females (74.3%), married (66.3%), employed (58.9%), and earning less than $100 monthly income (80.5%). The study participants came into the facility within Lagos State from Surulere (12.8%), Alimosho (12.1%), Oshodi-Isolo (11%), Kosofe (11%), and Mainland (6.7%) local government areas [LGA], respectively, and were approximately 9.49 (±4.8) km a walking distance from the facility. The common challenges faced by the participants were psychological (270/344), financial issues (234/344), and lack of food (140/344). The commonest psychological challenge experienced include fear (60%), depression (20%), and anxiety (16%). The support the participants will require to pull through the COVID-19-induced lockdown period was financial (56%), treatment support (24.4%), and food security (9.6%).

The predominance of PLWH who were involved in this study was within the modal age 41-50 years and predominantly female. This population reflects the client accessing care in employing our facility ab-initio, which is consistent with findings from previous works on HIV epidemiology,[16],[17] as well as the report of National HIV&AIDS and Reproductive Health Survey (NARHS).[18] The high rate of disclosure among the respondents may be aligned to the clinic's robust counselling sessions and adherence strategies as a majority of patients abide by instructions/guidelines offered by healthcare workers [counsellors, nurses, pharmacists, and doctors]. The low earning capacity [<$100] among the majority of respondents is not far-fetched as Nigeria being a Low- and Middle-Income country [LMIC] does not have the financial muscle as a significant proportion of Nigerians earn close to the minimum wage [$83 = 30000naira]. These traits might have modulated the understanding of the need to access care during the COVID-19-induced lockdown irrespective of the plausible limitations.

The Psychological issues varying from anxiety, depression, and fear among others are the most common form of challenge the respondents [PLWH] experienced during the lockdown. This could be alluded to the alternating feelings of living with HIV and the need for lifelong ARTs.[18],[19],[20],[21],[22] This is buttressed by the significant association between psychological issues and the long duration of ARTs. Furthermore, the psychological issues could be aggravated by the plausible risk of being infected with SARS-CoV-2, in addition to the socio-economic impact of the lockdown on daily survival, difficulty in accessing care, and the possible consequences.

Significant association was noted between financial related problems and the monthly income during the period of the COVID-19-induced lockdown. This is understandable considering the low monthly income of the study participants (less than $100) without any financial relief by the country's authorities; thus, meeting basic living needs are not guaranteed. The lack of food experienced could also be explained by the financial challenges and background low income of participants, in addition to little or no support from the government. This finding affirms the inextricable link between HIV and poverty.[20],[23],[24]

In view of the identified challenges, financial aids remain an important support measure required to pull through the lockdown though very few individuals received such from NGOs or the government. The economic fortunes of the country nosedived with gross reduction of crude oil prices, thus limiting the quantum of support and palliatives available to mitigate the effects of movement restrictions for the populace.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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