Abstract
BackgroundAccess to antiretroviral therapy has dramatically expanded in Africa in recent years, but there are no validated approaches to measure treatment adherence in these settings.MethodsIn 16 health facilities, we observed a retrospective cohort of patients initiating antiretroviral therapy. We constructed eight indicators of adherence and visit attendance during the first 18 months of treatment from data in clinic and pharmacy records and attendance logs. We measured the correlation among these measures and assessed how well each predicted changes in weight and CD4 count.ResultsWe followed 488 patients; 63.5% had 100% coverage of medicines during follow-up; 2.7% experienced a 30-day gap in treatment; 72.6% self-reported perfect adherence in all clinic visits; and 19.9% missed multiple clinic visits. After six months of treatment, mean weight gain was 3.9 kg and mean increase in CD4 count was 138.1 cells/mm3.Dispensing-based adherence, self-reported adherence, and consistent visit attendance were highly correlated. The first two types of adherence measure predicted gains in weight and CD4 count; consistent visit attendance was associated only with weight gain.ConclusionsThis study demonstrates that routine data in African health facilities can be used to monitor antiretroviral adherence at the patient and system level.
Highlights
Access to antiretroviral therapy has dramatically expanded in Africa in recent years, but there are no validated approaches to measure treatment adherence in these settings
Patient sample The study sample targeted 30 treatment naïve patients per facility who initiated antiretroviral therapy (ART) 8-24 months prior to data collection and who met the following inclusion criteria: (a) ≥ 18 years old; (b) no previous exposure to ART except for prevention of mother to child transmission (PMTCT); (c) follow-up data for ≥ 6 months after ART initiation, as indicated by one or more recorded clinic visits in two consecutive 3-month periods after initiation; (d) at least one adherence self-report or pill count in medical or pharmacy records in these two quarters; (e) data available on prescribed ART regimen and quantity dispensed during the follow-up period; (f) at least one CD4 count recorded within 3 months prior to initiation and in the 18 months after initiation
All models included: gender, age (30 or younger, 31-40, >40 years), whether married, capital-urban-rural clinic location, baseline CD4 level, WHO stage at ART initiation, time since ART initiation, evidence of TB at ART initiation, evidence of side effects or opportunistic infections since treatment initiation, number of different ART regimens, and whether the patient was ever treated with a protease inhibitor; weight change models included baseline weight
Summary
Access to antiretroviral therapy has dramatically expanded in Africa in recent years, but there are no validated approaches to measure treatment adherence in these settings. Global health initiatives have introduced antiretroviral therapy (ART) to ever-increasing numbers of HIV patients. Successful therapy depends on life-long adherence to these medications. Large-scale African ART program have reported mixed results on patient adherence to antiretrovirals (ARVs),[1] with some programs reporting high levels,[2,3] and some reporting much lower levels[4]. With rapidly expanding access to ARVs in resource-poor settings, it will be vital to monitor adherence and to identify interventions that can encourage sustained adherence. No validated approaches exist to measure adherence, especially in low resource settings with potentially poor data availability
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