Adherence to antiretroviral therapy in a clinical cohort of HIV-infected children in East Africa.

Rachel C Vreeman,Sarah E Wiehe,Deo Wabwire,Denis Nash,Kara Wools-Kaloustian,Beverly S Musick,Samuel O Ayaya,Constantin T Yiannoutsos,Craig R Cohen

doi:10.1371/journal.pone.0191848

Abstract

ObjectiveTo describe antiretroviral therapy (ART) adherence and associated factors for a large HIV-infected pediatric cohort followed by sites of the East Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) consortium.MethodsThis study utilized prospectively collected clinical data from HIV-infected children less than 13 years of age who initiated ART within 4 clinical care programs (with 26 clinical sites) in Kenya, Uganda, and Tanzania and were followed for up to 6 years. Programs used one of 3 adherence measures, including 7-day quantitative recall, 7-day categorical recall, and clinician pill assessments. We fit a hierarchical, three-level, logistic-regression model to examine adherence, with observations nested within patient, and patients within the 26 sites providing pediatric HIV data to this analysis.ResultsIn East Africa, 3,304 children, 52.0% male, were enrolled in care and were subsequently observed for a median of 92 weeks (inter-quartile range [IQR] 50.3–145.0 weeks). Median age at ART initiation was 5.5 years ([IQR] 3.0–8.5 years). “Good” adherence, as reported by each clinic’s measures, was extremely high, remaining on average above 90% throughout all years of follow-up. Longer time on ART was associated with higher adherence (adjusted Odds Ratio–aOR–per log-transformed week on ART: 1.095, 95% Confidence Interval–CI–[1.052–1.150].) Patients enrolled in higher-volume programs exhibited higher rates of clinician-assessed adherence (aOR per log-500 patients: 1.174, 95% CI [1.108–1.245]). Significant site-level variability in reported adherence was observed (0.28), with even higher variability among patients (0.71). In a sub-analysis, being an orphan at the start of ART was strongly associated with lower ART adherence rates (aOR: 0.919, 95% CI [0.864–0.976]).ConclusionsSelf-reported adherence remained high over a median of 1.8 years in HIV care, but varied according to patient-level and site-level factors. Consistent adherence monitoring with validated measures and attention to vulnerable groups is recommended.

Highlights

The advent of antiretroviral therapy (ART) has transformed HIV infection from a rapidly terminal illness into a chronic disease
Longer time on ART was associated with higher adherence Patients enrolled in higher-volume programs exhibited higher rates of clinician-assessed adherence
Patients who do not maintain adequate adherence to ART are at greater risk of viral resistance to the available antiretroviral drugs,[6,7,8,9,10] of immunologic decline resulting in opportunistic infections[11] and HIV disease progression,[12,13,14,15,16,17] and of transmitting resistant HIV at sexual debut.[18]

Summary

Introduction

The advent of antiretroviral therapy (ART) has transformed HIV infection from a rapidly terminal illness into a chronic disease. ART suppresses HIV replication, reduces HIV morbidity and mortality, and improves the lives of HIV-infected children [1,2,3,4,5] but successful long-term treatment depends on adherence to ART regimens. Patients who do not maintain adequate adherence to ART are at greater risk of viral resistance to the available antiretroviral drugs,[6,7,8,9,10] of immunologic decline resulting in opportunistic infections[11] and HIV disease progression,[12,13,14,15,16,17] and of transmitting resistant HIV at sexual debut.[18] Good ART adherence, typically defined as 90% or greater of doses taken as prescribed, decreases children’s HIV-related morbidity and mortality.[13, 19,20,21]. Non-adherence and subsequent viral resistance could eliminate children’s limited treatment options

Methods

Results

Conclusion