Treatment adherence
Nachega JB, Hislop M, Nguyen H, Dowdy DW, Chaisson RE, Regensberg L, Cotton M, Maartens G. Antiretroviral Therapy Adherence, Virologic and Immunologic Outcomes in Adolescents Compared With Adults in Southern Africa. J Acquir Immune Defic Syndr. 2009 Mar 11. [Epub ahead of print]
Nachega and colleagues aimed to determine adherence to and effectiveness of antiretroviral therapy in adolescents vs. adults in southern Africa in an observational cohort study originating from Aid for AIDS, a private sector disease management program in southern Africa. Adolescents (age 11-19 years; n = 154) and adults (n = 7622) initiating antiretroviral treatment between 1999 and 2006 and having a viral load measurement within 1 year after antiretroviral treatment initiation were included. The primary outcomes were virologic suppression (HIV viral load </=400 copies/mL), viral rebound, and CD4 T-cell count at 6, 12, 18, and 24 months after antiretroviral treatment initiation. Secondary outcome was adherence assessed by pharmacy refills at 6, 12, and 24 months. The authors used a multivariate loglinear regression and Cox proportional hazards. A significantly smaller proportion of adolescents achieved 100% adherence at each time point (adolescents: 20.7% at 6 months, 14.3% at 12 months, and 6.6% at 24 months; adults: 40.5%, 27.9%, and 20.6% at each time point, respectively; P <0.01). Patients achieving 100% 12-month adherence were significantly more likely to exhibit virologic suppression at 12 months, regardless of age. However, adolescents achieving virologic suppression had significantly shorter time to viral rebound (adjusted hazard ratio 2.03; 95% confidence interval: 1.31 to 3.13;P <0.003). Adolescents were less likely to experience long-term immunologic recovery despite initial CD4 T-cell counts comparable to adults. Compared with adults, adolescents in southern Africa are less adherent to antiretroviral treatment and have lower rates of virologic suppression and immunologic recovery and a higher rate of virologic rebound after initial suppression. Studies must determine specific barriers to adherence in this population and develop appropriate interventions.
Editors’ note: Both because the number of adolescents on antiretroviral treatment continues to expand and because this population is most likely to benefit from optimal adherence with longest life expectancy on optimal treatment, determining the underlying reasons for the poor adherence that increases risk of morbidity and drug resistance is urgent. This study assessed adherence and outcomes among adolescents started on antiretroviral treatment when their CD4+ counts fell to 350 cells whose parents were employed by companies participating in a private sector employer-subsidized medical insurance programme in 9 countries in southern Africa. The adolescents were less likely than were adults to be on the non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens which can achieve viral suppression with moderate levels (70-90%) of adherence. However, this cannot fully explain why adolescents were 50% less likely to maintain perfect adherence at all time points and were 70-75% less likely to be virologically suppressed at 1 and 2 years after treatment initiation. Equivalent studies in the public sector are needed to confirm these findings and qualitative studies are needed to determine the causes and provide avenues for solutions to what must be underscored as a priority treatment programme challenge.
Tuller DM, Bangsberg DR, Senkungu J, Ware NC, Emenyonu N, Weiser SD. Transportation Costs Impede Sustained Adherence and Access to HAART in a Clinic Population in Southwestern Uganda: A Qualitative Study. AIDS Behav. 2009 Mar 13. [Epub ahead of print]
The cost of transportation for monthly clinic visits has been identified as a potential barrier to antiretroviral adherence in sub-Saharan Africa and elsewhere, although there is limited data on this issue. Tuller and colleagues conducted open-ended interviews with 41 individuals living with HIV and attending a clinic in Mbarara, Uganda, to understand structural barriers to antiretroviral adherence and clinical care. Almost all respondents cited the need to locate funds for the monthly clinic visit as a constant source of stress and anxiety, and lack of money for transportation was a key factor in cases of missed doses and missed medical appointments. Participants struggled with competing demands between transport costs and other necessities such as food, housing and school fees. These findings suggest that transportation costs can compromise both antiretroviral adherence and access to care. Interventions that address this barrier will be important to ensure the success of antiretroviral programs in sub-Saharan Africa.
Editors' note: With mean per capita income in Uganda the equivalent of 25 USD per month and monthly refill visit roundtrip transport costs ranging from 0.60 to 11.75 USD, it is not surprising that serious sacrifices by patients are required in other essential arenas such as food and school fees. These findings suggest that the concept of ‘access to medicine or lack thereof’ rather than the concept of ‘failure to adhere’, reframes the problem of missed doses as one anchored in structural and financial barriers that need to be addressed by treatment programmes and communities. Many ideas come to mind for piloting such as decentralisation to deliver drugs directly to the community through drug dispensaries, primary care clinics, and home-based care, along with transport cost subsidization for those being stabilised on their regimens and for subsequent 6 monthly control visits.
Uzochukwu BS, Onwujekwe OE, Onoka AC, Okoli C, Uguru NP, Chukwuogo OI. Determinants of non-adherence to subsidized anti-retroviral treatment in southeast Nigeria. Health Policy Plan. 2009 Mar 10. [Epub ahead of print]
The antiretroviral treatment programme in Nigeria is delivered through selected teaching and mission hospitals at a free/subsidized rate. The government aims to scale up antiretroviral treatment in the country. However, non-adherence to antiretroviral medication can lead to viral resistance, treatment failure, toxicities and waste of financial resources. This study examined the factors responsible for non-adherence to free/subsidized antiretroviral treatment in south-east Nigeria. The study was cross-sectional and descriptive. Information was collected from 174 patients selected by simple random sampling from the register of all patients who had been on antiretroviral therapy for at least 12 months at the beginning of the study period. Patients were identified during their clinic visits. Information on their socio-demographic profile, antiretroviral treatment and determinants of non-adherence to antiretroviral treatment was obtained from those who gave consent, using pre-tested interviewer-administered questionnaires. All patients clearly understood the need to take antiretroviral drugs throughout their lives, and what the costs entailed. They understood the need for periodic testing, the probability that complications would develop, cost of transportation to treatment site and the daily treatment regimen. Seventy-five per cent of respondents were not adhering fully to their drug regimen; the mean number of days that respondents had been off drugs was 3.57 days the preceding month. Reasons for non-adherence included: physical discomfort (side effects); non-availability of drugs at treatment site; forgetting to carry drugs during the day; fear of social rejection; treatment being a reminder of HIV status; and selling of own drugs to those unable to enrol in the projects. Being female, under 35 years, single, and having higher educational status were significantly associated with non-adherence. It is important that policy makers and programme managers address the factors responsible for non-adherence when scaling up subsidized ARV treatment in Nigeria and other parts of sub-Saharan Africa.
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