Assessment of ART Users Adherence to Their Treatment-Using Community Lead Monitoring (CLM) Initiative in Negele Arsi Town, West Arsi Zone, Oromia Region, Ethiopia

Background : TSD has been conducting a research project called “Community Led Monitoring (CLM)” in collaboration with the Negele Arsi City Health Department with funding from the US Embassy of PEPFAR. The project is being implemented at Negele Arsi Health Center and Negele Arsi Primary Hospital in the city in collaboration with the two KP ART Service Providing Centers. Methods : A mixedcross sectional mixed method was used. This study used was conducted on a total of 172 ART users, and 4 key informants were included. The qualitative data were transcribed, translated, coded, and analyzed thematically. Results : The respondents were interviewed for how long they have known their result and about 33.72 % of them more than 12 years ago. About 3.49 % of them knew their result with in the last one year. About 87.2 % of the respondents take their drugs regularly without interruption, the rest discontinued the reasons depicted the following pie chart


Introduction
Community-led monitoring of HIV ART adherence is a vital approach that engages individuals and communities affected by HIV in actively monitoring and supporting the adherence of antiretroviral therapy (ART) among people living with HIV (1,2).This innovative strategy empowers community members to play an active role in ensuring the successful management of HIV and improving health outcomes(3).Effective adherence to ART is crucial for achieving viral suppression, reducing HIV transmission, and maintaining overall health and well-being(4).However, adherence challenges, such as pill burden, side effects, stigma, and lack of social support, can hinder individuals from consistently taking their medication as prescribed.Community-led monitoring of ART adherence aims to address these barriers by involving community members, including people living with HIV, in monitoring and supporting adherence practices(5).Through community-led monitoring, trained community members are equipped with the knowledge and skills to provide ongoing support, education, and reminders to individuals on ART(6).They work closely with healthcare providers to track adherence levels, identify challenges, and offer tailored interventions to promote adherence(7-9).This approach not only strengthens the bond between individuals and their communities but also fosters a sense of ownership and responsibility for individual health and the wellbeing of the broader community(6, 10).

Need of The Study.
The benefits of community-led monitoring of HIV ART adherence are multifold.It improves medication adherence rates, leading to better health outcomes and reduced viral load.By involving community members, this approach also helps to reduce stigma associated with HIV, as it normalizes the discussion around ART adherence and creates a supportive environment for individuals living with HIV.Furthermore, community-led monitoring promotes a patient-centered approach to healthcare, ensuring that the unique needs and challenges faced by individuals are taken into account.In conclusion, community-led monitoring of HIV ART adherence is an effective and empowering approach that recognizes the importance of community engagement in HIV management (11).By actively involving individuals and communities in monitoring and supporting ART adherence, we can enhance treatment outcomes, reduce HIV transmission rates, and foster a more inclusive and supportive environment for those living with HIV.This approach is a testament to the power of community-driven initiatives in transforming healthcare delivery and improving the lives of individuals affected by HIV Results of the Implementation TSD-CLM core team established: Before the signing of the project agreement, after we reached in the final step of signing of the agreement we have established a CLM core team at the organization level with member of 5 people (Executive Director, Program Manager, Area Coordinator, Regional Coordinator and M&E coordinator).After forming the team, the proposal is briefly presented to the team member.The team members intensively discussed on the proposal and added their inputs to make it more applicable during the implementation.Detail Implementation Plan of the project is developed by the TSD-CLM members and they become ready to implement it.

Result:
• The established team supported to have responsible and comprehensive implementing body.
• Each of the team members incorporated CLM issue on their regular working program.

Town level CLM advisory team formed:
After sensitization of the assessment we have established town level CLM advisory group which it has 7 members (health office, ART site health facility, PLHIV/KP association, city council member).The major role of this team is to create fertile ground for the CLM process.Most of the team members represented by their office with sending letters.The established team developed its own action plan, decided meeting date and place, chairperson and secretary for the team.

Result:
• The Organized advisory groups created clarity about the CLM.
• Each of the concerned bodies appreciated the implementation of CLM and took their responsibilities.

4.2.
Target hot spot areas (villages) selected: The TSD CLM team in collaboration with town level CLM advisory group selected 5 hotspot areas in the town.Even though there are different residence areas of KPs but the selected hotspot areas are the major residence areas about 80 % of HIV Positive KPs are leaving in.Most of the hotspot areas are business areas, broker's villages and an area lower income people are living in.The identification of the hotspot areas made based on the previous experience of TSD and the town level CLM advisory group recommendation based on the data they have.

Result:
• Identifying the hotspot areas assisted the implementation, in order to avoid unnecessary time and wastage.

4.3.
Literate active KPs and interns selected: 15 literates active KPs and 2 interns selected for data collection and validation.Before the selection of data collectors and interns' selection criteria was developed by TSD CLM team and town level CLM Advisory group.The major selection criteria were; for KPs: can read and write, PLHIV, who has an experience in peer education, who has better discipline and for interns who has voluntary service.Based on the selection criteria the above mentioned KPs and interns were selected.A KP (Key Population) ART friendly service provider gave us data, that are current on ART of the Health Center are 540.

Result:
• Data collectors and supervisors selected with clear selection criteria.
• Most of the selected data collectors are interested to engage in, because of they believed that CLM can solve their problems on ART service provision.• Interviewee are happy to respond because of almost all of the data collectors are PLHIV and there is not confidentiality problem.

4.4.
The project sensitized for staff and key stakeholders: 31 key staff, CLM advisory team, interns and volunteers attended in the sensitization workshop of the project.The sensitization workshop had been conducted in Negele Arsi town.In the sensitization the overall planned activities of CLM was presented for the stakeholders and inform their roles in the process.
Accordingly, the participants shared their experiences and they think about what they are currently doing and that the purpose of the project would be encouraging and transformative.

Result:
• All concerned stakeholders become on the same page in related to CLM.
• Each of them (from the government and target community side) appreciated and shown their commitment CLM to be applicable.4.5.Data Collection Tool Developed and Translated: Data Collection tool with 51 questions developed.The questioner developed by TSD CLM team.The questioner has 7 major parts; the first Demographic Data with 10 questions, second Information about her HIV positivity and ART adherence status with 8 questions, third enablers and barriers to get ART service at health facility level with 9 questions and the forth part is service providers' behavior and service provision approach for ART service users with 11, the fifth availability with 3 questions, the six accessibility with 3 questions and the seventh is quality of service with 2 questions one with four subsections.The questioners developed based on the practical experience of the organization.After properly developed, it translated to local language 'Amharic'.TSD gave orientation for volunteers and requested them to comment on the questioner (data collection tool) and to read each question and ask if it was appropriate for the respondents to ask questions.

Result:
• A standard data collection tool developed with full involvement of each stakeholder.
• The developed tool translated and became ready for data collection.

4.6.
First round Data Collected: Two types of data collection tool (Qualitative and Quantitative) have been developed.The quantitative data collection tool with 51 questions prepared and translated.The questioner was adopted from the previously used one in Shashemene for the same assessment.The quantitative data is summarized and articulated using KOBO collect tool the qualitative data were also analyzed manually.

Result:
• Data collection tool with 51 questions prepared and translated.
• Data /input/ collected/generated based on the final approved tool.
• 2 interns were assigned & investigated the behavior of both the user and service providers as qualitative data both at the health center and hospital

First round Analysis Conducted:
The findings of collected data were analyzed in two ways the quantitative data were analyzed with Kobo toolbox and the qualitative data was also analyzed manually.According to information obtained from the health center of the town there are 450 KP (Key Population) ART users till the start of the CLM.We engaged all (172) of them found in the town and the data collection process took 4 consecutive weeks.On the first cycle of the CLM, the qualitative and quantitative preliminary finding was generated.

Demographic Data
The socio demographic characteristics of the respondents are crucial to understand their social status.If we take some of the demographic data of the respondent in terms of Age, originally where they are from, marital status, and level of education and etc., Age: 16.9% of them are 25-29, 8.7% 24 and below, 20.3% 29-34, and the remaining 51.4 % of them are above to 35.Originality they are from 28.5 % surrounding rural kebeles of Negele Arsi.19.8 % Born and grown in Negele Arsi Town.About 11.6 % of the respondents are commercial sex workers.The majority of their marital status is divorced (29.9 %).About 72.1 % of the respondents has no regular sex partner.Regarding the education level, 32.6 % of them are illiterates (unable to read and write).About 86.6 % of the respondents have children (Table 1) The respondents were interviewed for how long they have known their result and about 33.72 % of them more than 12 years ago.About 3.49 % of them knew their result with in the last one year.

Table 2: The time at which the respondents knew their HIV result
All respondents already started ART at the specific time displayed in the graph below The time at which the respondents started their ART About 87.2 % of the respondents take their drugs regularly without interruption, the rest discontinued the reasons depicted the following pie chart.

Fig 2: Reason for discontinuation of their treatment (ART)
In the above pie chart the other option consists of 5.81 %, these reasons specified as follows • Going to the holy water and ART medications were not available there.
• Going to a remote site for work and ART • Medications were not available.
• There was a time where I was so much depressed and economically debilitated to the extent of lack of food, these led me default my ART medication.• Due to travel to other area • Because sometimes I feel desperate in life and have my own personal problems.
• Due to dispute with family • Due to financial issues • Because of doctors suggestion • Due to my personal problem About 13.94 % of the respondents think there is a problem if they continue taking your ART.About 51.74 % of them collect their drug for six months, 44.19 % for three months and 2.33 % of them every month 4.8.3.Enablers and Barriers to get ART service at health facility level Clear explanation was given for why they are having tests for 7.6% respondents.There is a need of improvement in their care in the health facility for 46.5 % of them About 5.8 % of them are not told everything they want to know about their ART drugs The problem of discontinuing the ART drug is not told for 4.1 % of them During their consultation 14 % of them are not given little or no medical explanation I am given good advice on how to cope with HIV ART department care in the health facility is not satisfying for 10.5 % of them It's not easy to get an appointment for 6.7 % of them Much time is not given for their consultation for 7 % of them    Clients responded that they are satisfied with their last facility visit are 156 (90.67%).Among the satisfied clients 61.63 % of them satisfied on the Information they received about services and 29.07 % of them for Service Providers handling.

The qualitative findings of the assessment 5.1. At the town level health center
The supervisors and follow up team had a visit to Arsi-Negele town ART health center, as part of Observation of the behavior and approach of service providers during service.Here are the results of our observation… • The provider is able to • Maintain an open, non-judgmental attitude and actively listen to patient concerns and new complaints in a compassionate, respectful and caring manner.• Respect patient autonomy, privacy and confidentiality in the overall HIV care.
• Provide comprehensive education to patients about HIV/AIDS and its treatment options.
• Implement routine counselling on the critical importance adhering to the HAART medications and ART clinic follow up with nearly all patients.
• Follow patients at regular intervals to monitor changes in their health status related to drug side effect, development of potential opportunistic infection or adjustment to medication needed.• Encourage and support patient involvement in the development of their treatment plan and adhere to this plan accordingly.• Promote responsibility for clinical care by addressing any potential psychological, financial or social barriers that may prevent treatment adherence or success.However, the provider was not happy with the fact that their psychosocial support program to HIV positive pediatric age group patients, which they practice on a monthly basis, is now working less efficiently because of shortage of budget.• Actively assess all patients for potential treatment failure and facilitate access to timely care through coordination of referrals for specialized services such as mental health care and higher health facilities with better infectious disease care as needed.

At the Hospital
Negele primary hospital does not yet started ART service.Financial constraints are the significant obstacle that prevents the hospital from starting ART HIV clinic.Firstly establishing an ART HIV clinic requires specialized infrastructure and equipment to manage the medication, monitor patient progress, and administer regular tests.These costs can be challenging to bear particularly for those with limited funding on top of this Since the Budget is allocated by Oromia health bureau; still the bureau does not permit the hospital to start ART service despite efforts by hospital.Secondly the covid-19 pandemic has led to unprecedented challenges for healthcare systems worldwide.As the virus quickly spread across continents, hospitals found themselves overwhelmed with the number of patients requiring treatment.In response to this crisis, many hospitals decided to convert part or all of their facilities into Covid centers.Among those Negele primary Hospital is one of them that is changed to Covid centers here in Ethiopia in 2020 soon after its inauguration in 2019  counsel the patient about the disease, its treatments and the importance of adherence to medical therapy regimens as well as lifestyle modifications and linking to nearby ART clinic which is Negele health center" HIV positive Clients were interviewed for some kind of questions.Some of the services the clients received are HIV testing and diagnosis, management of opportunistic infections, counseling service and their confidentiality was kept.They start their follow up at Negele health center.The client's recommendation for the hospital "Hospital is more equipped, has more investigation modalities and better trained human power than the health center, it's better to start ART clinic"

Second round Analysis 6.1. Demographic Data
The socio demographic characteristics of the respondents are crucial to understand their social status.If we take some of the demographic data of the respondent in terms of Age, originally where they are from, marital status, and level of education and etc., Age: 18.6% of them are 25-29, 7% 24 and below, 10.

Information About HIV positivity and ART adherence Status
The respondents were interviewed for how long they have known their result and about 40.7 % of them more than 12 years ago.About 4.7 % of them knew their result with in the last one year.In the above pie chart, the other option consists of 17 %, these reasons specified as follows • Because of going to somewhere About 19.8 % of the respondents think there is a problem if they continue taking your ART.About 66.9 % of them collect their drug for six months, 32 % for three months and 0.6 % of them every month.About 97.7 % of clients get their drug without any problem 6.3.Enablers and Barriers to get ART service at health facility level Clear explanation was given for why they are having tests for 84.9 % respondents.There is a need of improvement in their care in the health facility for 45.9 % of them About 5.2 % of them are not told everything they want to know about their ART drugs The problem of discontinuing the ART drug is not told for 9.3 % of them During their consultation 15,7 % of them are not given little or no medical explanation I am given good advice on how to cope with HIV (5.2%) ART department care in the health facility is not satisfying for 2.9 % of them It's not easy to get an appointment for 4.7 % of them Much time is not given for their consultation for 4.7 % of them  6.6.Accessibility of services About 0.6 % of the respondents did not receive adequate information about the HIV services they received in their last facility visit.Service fee was asked from KPs from 9.7 % of them (7 % of them for ART medicines and 1.2 % for opportunistic infection drugs).More than three forth (77.3 %) of the respondents reported that they have no barriers to receive the service.However, 22.7 % Clients were reporting having barriers for accessing HIV services are for the following barriers.The whole health facility visits waiting time 20 minutes Clients responded that they are satisfied with their last facility visit are 171 (99.4%).Among the satisfied clients 57 % of them satisfied on the Information they received about services and 17.4 % of them for Service Providers handling.

Fig 1 :
Fig 1: The time at which the respondents started their ART Due to stigma related to ART.Other Fear of dependency on the drug.Due to Lack of confidentiality and privacy of the service Due to lack of good service in the facility.

Fig 4 :
Fig 4: Clients reporting service fees in their last facility visit More than three forth (79.65 %) of the respondents reported that they have no barriers to receive the service.However 20.35 % Clients were reporting having barriers for accessing HIV services are for the following barriers.• Cost of transportation 22 (12.79 %) • Inconvenient working hours 10 (5.81 %) • Distance 2 (1.16 %) • Cost of commodities and services 1 (0.58 %) which leaves the hospital no time to open ART services.Non ART HIV services can be provided in multiple ways, depending on the specific needs of the person living with HIV.Some examples include: HIV testing and diagnosis and management of opportunistic infections The Hospital has ART Focal who worked for the last one year, but did not taken ART training.The focal responded for the questions asked what do they do when there are HIV positive patients, " Educate and IJFMR240218252 Volume 6, Issue 2, March-April 2024 11

Fig 1 :Fig 2 :
Fig 1: The time at which the respondents started their ART

Fig 3 :
Fig 3: Absence of commodities encountered for HIV treatment in the facility

Fig 4 :
Fig 4: Clients reporting barriers for accessing HIV services

Table 1 : Socio demographic characteristics of the respondents
4.8.2.Information About her HIV positivity and ART adherence Status

.5. Availability of services About
14.53 % of the respondents have experienced absence of commodities during their last facility visit.Fig 3: Absence of commodities encountered for HIV treatment in the facility

Percentage Absence of Commedities 4.8.6. Accessibility of services
About 6.98 % of the respondents did not receive adequate information about the HIV services they received in their last facility visit.Service fee was asked from KPs from 19.6 % of them.

Table 1 : Socio demographic characteristics of the respondents
5 % 29-34, and the remaining 64 % of them are above to 35.Originality they are from 24.4 % surrounding rural kebeles of Negele Arsi.22.7 % Born and grown in Negele Arsi Town.About 13.4 % of the respondents are commercial sex workers.The majority of their marital status is having husband (27.3 %).About 55.8 % of the respondents has no regular sex partner.Regarding the education level, 33.7 % of them are illiterates (unable to read and write).About 84.9 % of the respondents have children (Table1)

Table 3 :
Enablers and barriers to get ART service at health facility level Clear explanation was given for why I am having tests done.
Due to Lack of confidentiality and privacy of the service.Due to stigma related to ART.Fear of dependency on the drug.OtherVariablesAgreement status Number Percentage (%)

. Service Provider's behavior and service provision approach for ART service user About
7 % of the respondents see that their health care providers are not concerned about their clients (

.5. Availability of services About
16.3 % of the respondents have experienced absence of commodities during their last facility visit.

Table 6 : The main changes observed between CLM round one and two
• 6 families in dispute discussed with each other and able to identify reason of their dispute.Reconciliation of families• 5 person those in dispute due to personal problems and shortage of income advised and reconciled.3Theservice fees reported Identifying ART-KPs who are not user of the insurance