Abstract
BackgroundGeneralizable data are needed on the magnitude and determinants of adherence and virological suppression among patients on antiretroviral therapy (ART) in Africa.MethodsWe conducted a cross-sectional survey with chart abstraction, patient interviews and site assessments in a nationally representative sample of adults on ART for 6, 12 and 18 months at 20 sites in Rwanda. Adherence was assessed using 3- and 30-day patient recall. A systematically selected sub-sample had viral load (VL) measurements. Multivariable logistic regression examined predictors of non-perfect (<100%) 30-day adherence and detectable VL (>40 copies/ml).ResultsOverall, 1,417 adults were interviewed and 837 had VL measures. Ninety-four percent and 78% reported perfect adherence for the last 3 and 30 days, respectively. Eighty-three percent had undetectable VL. In adjusted models, characteristics independently associated with higher odds of non-perfect 30-day adherence were: being on ART for 18 months (vs. 6 months); younger age; reporting severe (vs. no or few) side effects in the prior 30 days; having no documentation of CD4 cell count at ART initiation (vs. having a CD4 cell count of <200 cells/µL); alcohol use; and attending sites which initiated ART services in 2003–2004 and 2005 (vs. 2006–2007); sites with ≥600 (vs. <600 patients) on ART; or sites with peer educators. Participation in an association for people living with HIV/AIDS; and receiving care at sites which regularly conduct home-visits were independently associated with lower odds of non-adherence. Higher odds of having a detectable VL were observed among patients at sites with peer educators. Being female; participating in an association for PLWHA; and using a reminder tool were independently associated with lower odds of having detectable VL.ConclusionsHigh levels of adherence and viral suppression were observed in the Rwandan national ART program, and associated with potentially modifiable factors.
Highlights
HIV care and treatment programs in subSaharan Africa have shifted from an emergency response with a focus on quickly initiating the sickest HIV-infected patients on antiretroviral therapy (ART) to building sustainable programs which provide lifelong treatment to very large numbers of patients across the HIV disease spectrum
A total of 1,951 patients were believed to have started ART 6, 12 and 18 months prior to data collection at the 20 study sites, 1,798 (92%) of whom were randomly selected for inclusion in the study
A total of 837 (59%) of the 1,417 participants received viral load assessments, including 331 (40%) who had been on ART for 6 months, 284 (34%) on for 12 months and 222 (27%) on for 18 months (Figure 1)
Summary
HIV care and treatment programs in subSaharan Africa have shifted from an emergency response with a focus on quickly initiating the sickest HIV-infected patients on antiretroviral therapy (ART) to building sustainable programs which provide lifelong treatment to very large numbers of patients across the HIV disease spectrum. A meta-analysis of 27 small observational studies (median sample size = 100 patients) conducted in Africa during a very early phase of ART scale-up reported adequate adherence among 77% of patients [11]. Virologic monitoring, an objective measure of adherence used regularly for patient management and program evaluation in highincome settings, is rarely conducted in Africa. A recent systematic review of 89 African studies with any virologic data conducted largely in urban settings reported undetectable viral loads among 78% of patients after six months of ART, 76% after 12 months, and 67% after 24 months [15]. Generalizable data are needed on the magnitude and determinants of adherence and virological suppression among patients on antiretroviral therapy (ART) in Africa
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