Abstract
BackgroundWith African health-care systems facing exploding demand for HIV care, reliable methods for assessing adherence and its influencing factors are needed to guide effective public-health measures. This study evaluated individual patient characteristics determining antiretroviral treatment (ART) adherence and the predictive values of different measures of adherence on virological treatment failure in a cohort of patients in a routine-care setting in Cameroon.MethodsLongitudinal study over 6-months following ART introduction, using patients questionnaires and hospital and pharmacy records.ResultsAt the end of the 6 months study period, 219 of 312 patients (70%) returned to the pharmacy to refill their medication, 17% (51) were lost to follow-up, 9% (28) were dead and 4% (14) were transferred to other care centres. Virological treatment failure at 6 months was experienced by 26 patients, representing 13% of patients with available viral load value. Pharmacy refill irregularity was the most powerful predictor (odds ratio 12.4; P < 0.001) of virological treatment failure, compared with CD4 cell count increase at 6 months (odds ratio 7.8; P = 0.002) or self-reported adherence at one month (odds ratio 1.1; P = 0.85). Low intensity of ART side-effects after one month was strongly associated with survival (odds ratio 0.11; P = 0.001). Patients starting ART with CD4 cell count <100 cells/mm3 had a greater risk of dying during the follow-up period (odds ratio 2.69; P = 0.02). Compared with asymptomatic CDC stage A patients, CDC stage B (odds ratio 5.72) and CDC stage C patients (odds ratio 16.9) had higher risk of becoming lost to follow-up (P < 0.001). In the multivariate analyses, pharmacy non-adherence was less frequent in women (adjusted odds ratio 0.56; P = 0.05) but more frequent in patients with high monthly income (odds ratio 3.24; P = 0.04).ConclusionPharmacy-refill adherence might be considered as an alternative to CD4 count monitoring for identification of patients at risk of virological failure, especially in resources-scarce countries. The study confirmed the difficulty in demonstrating clear associations of individual patient factors and treatment outcomes. The substantial loss to follow-up and deaths occurring within 6 months after initiating ART emphasise the need to understand the best timing of ART initiation and further elucidate and educate on the underlying reasons for delaying initiation of ART in resource-limited countries
Highlights
With African health-care systems facing exploding demand for Human immune deficiency virus (HIV) care, reliable methods for assessing adherence and its influencing factors are needed to guide effective public-health measures
Access to HIV care in Sub-Saharan Africa has been improved by reduction in the cost of antiretroviral treatment (ART) and by the implementation of World Health Organization (WHO) guidelines promoting scaling-up by task shifting for clinical decision-making to less specialised health-care workers [1]
Long-term good ART adherence has been observed in certain settings of public sectors in Africa (Nachega, data presented at 16th Conference on Retroviruses and Opportunistic Infections 2009), the magnitude of this challenge in Sub-Saharan Africa remains large [2] and there is growing evidence for high rates of patients loss to follow-up [3,4]: a recent review reported that ART programmes in Africa retain only about 60% of their patients after two years on ART [5]
Summary
With African health-care systems facing exploding demand for HIV care, reliable methods for assessing adherence and its influencing factors are needed to guide effective public-health measures. Access to HIV care in Sub-Saharan Africa has been improved by reduction in the cost of ART and by the implementation of WHO guidelines promoting scaling-up by task shifting for clinical decision-making to less specialised health-care workers [1]. The challenge to achieve high adherence to ART is acute in Sub-Saharan Africa as the high rates of HIV/AIDS lead to greater absolute numbers of affected individuals than in other low-income regions. The cost of drugs has gone through several phases of reduction since a pilot antiretroviral drug delivery programme started in 2000, the implementation of a national decentralisation programme for HIV care in 2006 led to existing health infrastructures being overwhelmed by a huge demand for treatment. The overcrowding of HIV care centres has recently increased, as free treatment began to be available in May 2007
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