On-Time Appointment Keeping and Associated Factors among Human Immunodeficiency Virus-Positive Adult Patients Accessing Antiretroviral Therapy at Health Centers in East Gojjam Zone, Northwest Ethiopia, 2019

Background The magnitude of on-time appointment keeping among HIV-positive adult patients was not identified in Ethiopia. Hence, this study aimed to assess on-time appointment keeping and associated factors among human immunodeficiency virus-positive patients accessing antiretroviral therapy in the East Gojjam Zone, Northwest Ethiopia. Methods A community-based cross-sectional study was performed on 830 HIV-positive patients from April 1 to May 10, 2019, in East Gojjam Zone. A systematic random sampling technique was used to include study subjects, and data were collected through face-to-face interviews. Bivariable and multivariable binary logistic regression analyses were performed. Independent variables with a P value of <0.05 were considered statistically significant cut points. Results The prevalence of on-time appointment keeping was 62.1%. Being >24 years old (adjusted odds ratio (AOR) = 2.13; 95% confidence interval (CI) = 1.54–4.25), being unmarried (AOR = 0.59; 95% CI = 0.45–0.82), taking a drug regimen of tenofovir + lamivudine (3TC) + efavirenz (EFV) (AOR = 2.11; 95% CI = 1.84–3.62), taking ART ≥12 months (AOR = 4.32; 95% CI = 2.22–8.40), having a mobile (AOR = 2.22; 95% CI = 1.44–3.64), and getting adherence support (AOR = 1.83; 95% CI = 1.16; 95% 1.16–3.50) were significant factors. Conclusion On-time appointment keeping was low. Adherence support and appointment reminders should be strengthened.


Background
Adherence to antiretroviral therapy (ART) is an inclusive idea consisting of two basic components: medication adherence and on-time attendance at scheduled clinic appointments [1].Appointments are classifed as "on-time" if the patients attend the clinic within seven days of the scheduled clinic appointment [2].On-time appointment keeping provides a high-level assessment of how well populations of patients at a clinic perform in picking up prescribed ART on or before the pill run-out date.It also estimates clinic performance in successfully engaging patients to attend scheduled appointments [2].Te World Health Organization (WHO) recommended that the acceptable clinic-level performance of on-time appointment keeping should be above 80% [2].It is vital for 100% lifetime medication adherence [3].
In the management of human immunodefciency virus (HIV) and acquired immune defciency syndrome (AIDS), ontime clinical attendance for pharmacy reflls, laboratory investigations, and clinician assessments are crucial for successful treatment achievements and good clinical outcomes [4].When patients miss scheduled appointments, the opportunity to early identify and manage treatment failure vanishes [4,5].
Although medication adherence is supposed to be the most important factor in treatment outcome, the previous study has revealed that missed clinic appointments from ART clinics are signifcantly associated with virological failure [6], drug resistance, and an increased risk of AIDSrelated illness or death [5].
Even though there has been increased public and patient awareness of the ways of immunodefciency virus (HIV) infection prevention and the benefts of antiretroviral therapy (ART) globally [7], the interruption of scheduled clinical appointments has been high in Africa [8].Healthcare delivery systems, patient-related, sociodemographic, psychosocial, and clinical-related factors are associated with clinic appointment attendance [9,10].Sometimes HIVpositive patients are appointed orally.Tis leads to missing the appointment [5].
Antiretroviral therapy (ART) distribution and HIV/ AIDS preventive programs are both localized in Ethiopia.As a result of prior research's primary focus on medication adherence, Ethiopia's current HIV treatment strategy is faith based [5], but there is limited evidence for the magnitude of on-time appointment keeping and associated factors [11].Terefore, this study aimed to assess on-time appointment keeping and associated factors among human immunodefciency virus-positive adult patients accessing antiretroviral therapy at health centers in East Gojjam Zone, Northwest Ethiopia.

Study Design Setting.
A community-based crosssectional study design was performed from April 1 to May 10, 2019, at government health centers in East Gojjam Zone.Tis zone is found in the Amhara region, of Northwest Ethiopia.It is the second most populated zone in the region, with 2,719,119 total estimated population.Tere were eight government hospitals and 102 government health centers in this zone.Out of the total government health facilities, all hospitals and 23 health centers provided ART services and care for patients.About 11302 HIV-positive patients received ART at these health facilities [12].All adult HIVpositive patients receiving ART and having scheduled appointments from May 03/2018 to May 03/2019, at selected government health centers in East Gojjam Zone were included in the study.In contrast, HIV-positive women who were pregnant, labouring, lactating women, or seriously ill patients were excluded.Tose HIV-positive patients whose appointments had no registered appointment dates were also excluded.

Sample Size Determination and Sampling Technique.
Te sample size was determined using a single population formula.It was calculated via the formula (n � ((Z/2) 2 P (1 − P))/S 2 ) with consideration of a 95% confdence interval and 5% margin error (S).Te assumption of on-time appointment keeping of 43% was taken from the study conducted in three countries of Africa [5].Te calculated sample size was 377.Tis calculated sample size was also multiplied by the design efect of 2, and by adding 10% nonresponse, the total sample size was 830.A multistage sampling technique was employed to select study participants.Te lottery method, a simple random sampling technique, was used to select 8 governmental health centers from 23 governmental health centers.Te total sample size was proportionally distributed to eight governmental health centers.A total of 6139 eligible HIV-positive patients attended ART at selected health centers.During the time of the health center visit, study participants were selected by systematic random sampling at intervals of seven from each health center.

Data Collection Procedure.
Based on a review of pertinent literature [13,14], a structured questionnaire (Appendix 3) and checklist (Appendix 2) were designed.As identifers, patient record numbers were used to connect patients with their medical histories.Primary data were gathered by HIV-positive community health workers who had completed grade ten or higher in education (HIVpositive voluntary community health workers are also employed as ART defaulter tracers in Ethiopia.)and conducted face-to-face interviews with patients.Patients' addresses were obtained from health centers.Home visits served as the method for gathering data.Secondary data were also taken from the medical records of chosen ART patients.
Te dependent variable was on-time appointment keeping.Appointment keeping can be easily accessed from attendance records.If a patient has been visiting within seven days of all scheduled clinic appointments for 12 months, or within 24-48 hours before the "original" scheduled appointment [15], it is scored as 1 (yes); if a person has missed one or more scheduled clinic appointments for any reason(s), it is scored as 0 (no) [16].Tis study did not consider unscheduled visits to an emergency room, an inpatient ward, or any ward [15].Independent variables were sociodemographic (such as sex, age, residence, educational status, occupation, marital status, and monthly income), healthcare delivery systems (such as paper-based appointments, follow-up counseling, ever-faced unavailability of health workers, appointment time convenience, and satisfaction), patient-related, psychosocial (Appendix 3), and clinical-related factors (Appendix 2).Te perceived social stigma was assessed using ten questions with "yes" or "no" response choices [17].Perceived stigma was defned by having at least 1 yes answer out of the 10 questions.Satisfaction was measured by using sixteen questions [18].Satisfaction was defned as having equal to median or above median of 16 satisfaction-related questions.
2.4.Data Quality Control.Before data collection, a questionnaire was translated into the local language (Amharic) and converted back into English to check its consistency.Two days of training were given to eight data collectors and four supervisors about the data collection process.To check the consistency of the questionnaire, a pretest was performed.Te collected data were checked for completeness 2 AIDS Research and Treatment and consistency daily by supervisors.Before data entry, the completeness and consistency of the data were also checked.

Data Entry and Analysis.
After checking data completeness, it was coded and entered into EpiData version 3.1, and then it was exported to SPSS version 23 for analysis.Before binary logistic regression analysis, descriptive analysis was performed.A bivariable analysis was conducted.Independent variables with a P value of <0.2 in bivariable binary logistic regression analysis were selected for multivariable binary logistic regression analysis.A multivariable binary logistic regression analysis was performed.Each independent variable with a p value of less than 0.05 was considered a statistically signifcant cut point in multivariable binary logistic regression analysis.Seven hundred and thirteen (86.4%) had normal nutritional status.More than half (475, or 57.6%) of the study participants have taken the TDF + 3TC + EFV drug regimen.Five hundred thirty-three (64.6%) people encountered an opportunistic infection.More than three-fourths, or 649 (78.7%), of participants, did not experience side efects (Table 2).

Psychosocial, Behavioral, and Healthcare Delivery System
Characteristics.More than three-ffths of study participants had not faced stigma.Four hundred ninety-fve (60.0%) were members of the PLWHA association.Tree-fourths (74.2%) of the study participants had not received social support.

Outcome Data.
Of the total study participants, 512 (62.1%; 95% CI: 58.9%-65.3%)participants attended ontime appointments.Among the study participants who missed scheduled appointments, 159 (50.8%) and 87 (27.8%) missed the appointments due to forgetfulness and hopelessness, respectively (Figure 1).Tose patients who have disclosed their HIV-positive status to their family members had an increased odds of 1.79 (AOR � 1.79; 95% CI: 1.14-3.23) of keeping an on-time appointment as compared to patients who have not disclosed their HIV-positive status to their family members.Patients who had paper-based appointments had an increased odds of 2.16 (AOR � 2.16; 95% CI: 1.16-3.50) of keeping on-time appointments as compared to those who did not have paper-based appointments (Table 4).

Discussion
Te main objective of this study was to assess on-time appointment keeping and associated factors.Based on this objective, the prevalence of on-time appointment keeping was 62.1% (95% CI: 58.9%-65.3%).It is similar to the fndings of the WHO Global Report from 50 countries (58%) [5].Tis fnding is lower than those of the studies conducted in East Africa, at 75.8% [19], Cambodia at 79.6% [20], Florida at 72.1% [21], and Malaysia at 81.3% [15].Adult HIV patients often struggle with attendance at medical appointments due to various factors including work and childcare demands, lack of medical comorbidities, transportation issues, substance abuse, and untreated mental health conditions [22].Te discrepancy can be because of how HIV services are delivered diferently.Currently, 95% of HIV services in Ethiopia are provided at facilities [23].

AIDS Research and Treatment
Contrarily, HIV services are delivered diferently and in communities in other nations, which may have an impact on how often people keep their appointments.
Te study found that factors such as sex, age, marital status, ART regimen, adherence support, family member disclosure, mobile access, and paper-based appointments signifcantly contribute to on-time appointment keeping in HIV treatment.
Females had increased odds of 1.49 of keeping an appointment on time compared to males.Tis is consistent with the fndings of a study conducted in Uganda [24].Tis might be due to the fact that men are more likely to use psychoactive substances such as alcohol, leading to depression and forgetting appointment times than women [25].
Another independent factor for on-time appointment keeping was age.Patients who were older than 24 years had almost fourfold higher odds of on-time appointment keeping than those who were aged between 18 and 24 years.Tis fnding is congruent with that of the study conducted in Uganda [24].Te possible justifcation is that older age groups have a greater perception of health, or patients who are younger have diferent lifestyles (i.e., work or school   AIDS Research and Treatment status) that prevent them from maintaining consistent medical appointment attendance [21].Patients who were unmarried had decreased odds of 41% of keeping on-time appointments compared to patients who were married.Tis could be because widowed patients were unable to receive partner support (emotional support) from their partners [24,26,27] or because they felt hopeless [28], both of which could have caused them to miss visits.
Patients who were taking the drug regimen of TDF + 3TC + EFV had an almost threefold increase in odds of on-time appointment keeping compared to those who were taking the regimen of another drug (AZT + 3TC + EFV, AZT + 3TC + NVP, or TDF + 3TC + NVP).A possible justifcation might be the presence of side efects.Patients may experience side efects such as nausea, dizziness, or fatigue, which can make it difcult for them to attend their health facility appointments regularly.In addition, the high pill burden associated with these regimens may lead to nonadherence and missed appointments [14,29].HIV-positive patients who were taking ART drugs for ≥12 months had fourfold higher odds of keeping on-time appointments than those patients who were taking ART drugs for less than 12 months.Patients who have taken ARTdrugs for <12 months may have adverse drug events, existing coinfections and/or comorbidities, severely low hemoglobin, a low body mass index (severe malnutrition), and/or very low CD4 counts [14,29], which may cause them to miss the scheduled appointment.
Patients with mobiles had twofold higher odds of keeping on-time appointments than those without mobiles.Tis might be because patients who have mobile devices could receive a phone call or a reminder message from the healthcare providers.Mobile phone calling or messaging as a reminder improves adherence and clinic attendance [30].
Concerning adherence support from peer support groups, patients who have gotten adherence support from peer support groups had a more than 3-fold increase in the odds of on-time appointment keeping as compared to those patients who have not received adherence support from peer support groups.Tis is congruent with the fndings of studies conducted in Uganda [31] and Malaysia [30].Tis might be because patients with adherence support from peer support groups could get emotional support [24], which may impose on-time appointment keeping.
Furthermore, patients who disclosed their HIV-positive status to family members had a threefold increase in the odds of an on-time appointment keeping as compared with those who did not disclose their HIV-positive status.Tis might be because those patients who disclosed their HIV-positive status to their family members have gotten ART adherence and emotional support [24], which may enforce ontime appointment keeping.
Moreover, patients appointed with paper-based appointments experienced a sixfold increase in the odds of ontime appointment keeping as compared to those not appointed with paper-based appointments.Tis is in line with the fnding of a study conducted in Africa [19].A possible justifcation could be that patients who have appointments on paper will be less likely to forget [32].

Limitation of the Study.
To avoid disclosure issues, data collectors were selected from the same health centers where the study participants were living.Tis could create an information bias.

Conclusion
Te on-time appointment keeping was found to be lower than the WHO recommendations.Being female, being greater than 24 years old, being widowed, taking the regimen of TDF + 3TC + EFV, taking ART drugs for ≥12 months, having gotten adhesion support from peer support groups, disclosing HIV-positive status to a family member, having a mobile, and having paper-based appointments were factors that were signifcantly associated with on-time appointment keeping.Adherence support from family members, partners, and peer support groups, side efect management, and appointment reminders should be strengthened to increase on-time appointment keeping.

Figure 1 :
Figure 1: Reasons for missing appointments from ART clinic in East Gojjam Zone Northwest Ethiopia, 2019.
On-Time Appointment Keeping.
Tose patients who had mobiles had an increased odds of 2.29 (AOR � 2.29; 95% CI: 1.44-3.64) of keeping on-time appointments as compared to those who did not have mobiles.Patients who have gotten adherence support from peer support groups had an increased odds of 1.83 (AOR � 1.83; 95% CI: 1.21-3.34) of keeping on-time appointments compared to those patients who have not gotten adherence support from peer support groups.

Table 1 :
Sociodemographic and economic characteristics of HIV-positive patients accessing ART at health centers in East Gojjam Zone, Northwest Ethiopia, 2019.

Table 2 :
Clinical characteristics of HIV-positive patients accessing ART at health centers in East Gojjam Zone, Northwest Ethiopia, 2019.

Table 3 :
Psychosocial, behavioral, and healthcare delivery system characteristics of HIV-positive patients accessing ART at health centers in East Gojjam Zone, Northwest Ethiopia, 2019.

Table 4 :
Bivariable and multivariable logistic regression analysis of factors associated with on-time appointment keeping among HIV/AIDS-positive patients accessing ART at health centers in East Gojjam Zone, Northwest Ethiopia, 2019.