The WHO and WHY of antiretroviral treatment adherence

Successful antiretroviral (ARV) treatment depends on whether patients take their medication consistently and over a long period. This means taking the correct dosage, on time and in the correct way – either with or without food. KARL PELTZER et al looked at which patients unfailingly take their medication and why. 

More potent ARV regimens can allow for effective viral suppression at moderate levels of adherence, but if patients take the medication irregularly, it can lead to the development of drug-resistant strains of the virus. In countries where resources are limited and where clinics provide older first-line therapies, the development and transmission of drug-resistant strains of HIV will greatly limit the treatment options available.

The aim of this study was to assess those factors, including the information, motivation and behaviour that contributed to patients consistently adhering to the strict regime required when taking HIV/AIDS medication.

In countries where resources are limited and where clinics provide older first-line therapies, the development and transmission of drug-resistant strains of HIV will greatly limit the treatment options available.

Using systematic sampling, 735 HIV-positive patients were selected from outpatient departments at three public hospitals in Uthukela health district, KwaZulu-Natal, before they commenced with ARV treatment, and then followed up six months afterwards. HIV treatment is provided free of charge. The treatment programme provides patients with access to counselling, nutritional assistance, psychosocial support and social welfare evaluation.

After six months, the patients were interviewed using an anonymous questionnaire. Questions included socio-demographic characteristics, clinical history, health-related characteristics and health beliefs. Clinical data was obtained from their medical charts.

What was found?

Of the 735 patients (29.8% male and 70.2% female) who completed assessments before starting on ARVs, 519 were able to complete the assessment at the six months follow-up. Of these, 411 patients (79.2%) received combinatons of Lamivudine (3TC), Stavudine (d4T) + Efavirenz (Stocrin) and 108 (20.8%) Lamivudine (3TC), Stavudine (d4T) + Nevirapine. Fixed-dose combinations of ARVs were not available for patients.

Nearly three-quarters (73.5%) of the 519 patients who had initiated ARVs in this sample were female, 62.2% of whom were between 30 and 49 years old. Nearly three-quarters (73.3%) were never married, 61.9% had Grade 8 or higher formal education, almost all (98.8%) were Zulu and the largest religious affiliation was to charismatic churches (38.5%).

Those participants who lived in urban areas took their medication almost three times more faithfully than those living in rural areas.

The majority of the sample (61.7%) lived in rural areas and was unemployed (59.6%). Only 31.7% of respondents had a formal salary as their main source of household income and 52.5% received a disability grant.

... adherence was lower in people with depression and those who scored low on questions about their environment.

The minimum level of adherence required for ARVs to work effectively is 95%. Of the study group, 427 patients (82.9%) were 95% adherent in the month prior to the survey; 15.5% of patients were non-adherent (having missed at least one full day of medication in the past four days) and 70.8% of patients were adherent on all parameters (dose, schedule and food).

What determines adherence?

Those participants who lived in urban areas took their medication almost three times more faithfully than those living in rural areas. Living in an urban area is likely to be associated with lower transport costs and fewer disruptions in access to medication. Patients taking herbal medicine were less adherent, and those with lower levels of education, or single, separated, divorced or widowed, adhered better to their treatment than those who were married or were living together.

The adherence rate found in this study seems to be good.

When considering health-related variables, ad- herence was lower in people with depression and those who scored low on questions about their environment (safety, healthy physical environment, employed, access to information, transport, access to health services).

The dose, schedule and food adherence indicator found that adherence was 3.3 times higher among patients with a CD4 count above 200 cells/uL, and 4.6 times greater among patients with the 3TC, d4T + Nevirapine regimen.

The ‘spirituality/religion/personal beliefs' domain contained items about whether the respondent considered their lives to be meaningful; to what extent they are bothered about others blaming them for their illness; and whether they fear for the future or worry about death and dying because of HIV. Higher scores (more positive attitudes about life and fewer worries about dying) in this domain were associated with lower adherence. These patients may have a lower perceived need for antiretroviral therapy than other patients.

Policy implications

The adherence rate found in this study seems to be good. For the patients in this study, particularly those not living in urban areas, additional support may be needed to ensure patients are able to attend appointments or obtain their medication more easily. Adherence information and behavioural skills should be strengthened to improve adherence.

Although caution is urged in generalising findings to other districts and provinces in the country, the results generally support the findings from other adherence studies in southern Africa.

This is an abbreviated version of an open access article that appeared inBMC Public Health 2010, 10:111e, available on http://www.biomedcentral.com/1471-2458/10/111.

Karl Peltzer, Social Aspects of HIV/AIDS and Health, HSRC; Natalie Friend-du Preez, Department of Psychology, University of the Free State, Bloemfontein; Shandir Ramlagan, HSRC; and Jane Anderson, Centre for Population Studies, London School of Hygiene and Tropical Medicine, UK.