From access to adherence

As efforts are implemented to improve the provision of antiretroviral therapy (ART) to people with HIV and AIDS, factors influencing adherence to the drugs (ARVs) play a crucial role in improving health and preventing resistance to ARVs. Charles Hongoro and Harsha Dayal share a study on factors that influence the correct and consistent use of ARVs in urban and resource-poor areas.

The Treatment Action Campaign reported that by the end of January 2006, 111 607 and 90 000 people in the public and private sectors respectively were on ART. According to the department of health, 1.4 million people will require ART by 2009. With 5.54 million currently infected with HIV, there is now a dual challenge for the public health system: ensuring further access to those who meet the treatment criteria, as well as keeping those who are initiated, successfully within the programme.

The study was conducted in 20 accredited ART public health facilities in four provinces, namely Gauteng, Mpumalanga, KwaZulu-Natal and the Eastern Cape. Two districts representing urban, peri-urban and/or rural settings were selected in each of the four provinces.

The study involved 2 114 participants who have been on ARVs for a minimum of six months. Different measurements were used to provide information on the extent of adherence problems, as well as to why patients may not adhere.

Each participant was requested to recall the number of missed dosages for each medication taken in the past four days. The majority of respondents (97%) were on the first line of treatment offered in the public sector, namely Aspen Lamivudine/3TC, Stavudine/Stavir, Stocrin/Efavirenz and Nevirapine.

This self-reported adherence was further confirmed by an improvement in their mean CD4 count.

Dealing with side effects

The symptoms that bothered participants most as side effects in taking the first line of treatment ranged from physical changes to the body, to psychological problems due to their current health status and the treatment thereof (Table 1). A significant number of respondents experienced neurological changes affecting their hands and feet.

Psychosocial attitudes to medication

Respondents were asked to recall their emotional status over the past week, and possible reasons for missing a dose over the last month. Between 20-40% of respondents reported that they felt sad and lonely, had trouble sleeping and that everything they did was an effort. However, despite these reported side effects, Table 2 shows a high level of adherence on the four-day dose recall. More than 95% reported never missing a dose in the last month for any of the reasons listed.

Access to basic services

Access to basic services such as water, sanitation and electricity was varied among the respondents. Access to piped water was 89.1%, electricity 76.6% and 44.9% reported having flush toilets. Almost half of the respondents (48.8%) reported using a pit latrine system, and a further 92 respondents (4.4% of the sample) stated that they had no access to sanitation facilities.

Accompanying costs to treatment

Participation costs were incurred even though access to treatment is free at point of contact in all public health facilities (Table 3). Despite a high rate of unemployment among the respondents it did not mean that that they stopped taking their medication. The average distance travelled was 19.45 km to access the health facility and taxis were the main mode of transport.

Monitoring and evaluation

While all facilities complied with provincial requirements for the type of data items to be captured and reported on, monitoring systems to inform individual facility performance was varied and, in some cases, non-existent.

With the rapid increase in the number of patients being registered on the programme, facility managers and other staff reported that monitoring defaulters, following up on them and supporting their efforts to remain on the programme, requires full-time staff to focus solely on ensuring adherence, which was not possible for the majority of facilities.

From emergency mode to chronic care

Even though this study shows an exceptionally high rate of adherence, sustaining these levels for future treatment success, reducing drug resistance and improving the quality of life among people living with HIV/AIDS, requires a shift from an emergency mode of service provision, towards a chronic care model, as more and more people are targeted to access the ART roll-out programme.

The accreditation process needs to be reviewed with a focus on improving the capacity of existing sites as well as decentralising to primary levels as more sites are being accredited.

Systems for patient monitoring and facility evaluations need to be strengthened and built into the monitoring and evaluation framework from the onset. Facility managers need to become active participants in planning, monitoring, evaluating and revising models of delivery. Task shifting, away from a doctor-model of care, is proving to be more effective in ensuring follow-up of patients who have been successfully initiated into the programme. In addition to improving and strengthening healthcare programmes, tackling socio-economic and cultural factors through programmes designed to reduce women's dependence on state support, addressing gender inequalities at the household and community level and empowering women through social networks and effective employment remain the primary challenges in successful treatment.

With the rapid increase in the number of patients being registered on the programme, facility managers and other staff reported that monitoring defaulters requires full-time staff to focus solely on ensuring adherence.

Dr Charles Hongoro is the principal investigator of the study and director in the Policy Analysis and Capacity Enhancement (PACE) unit, Harsha Dayal is a researcher, assisted by Mr Tshumu Mongane, a PhD intern, who passed away earlier this year.