Adherence Is Not a Barrier to Successful Antiretroviral Therapy
Adherence Is Not a Barrier to Successful Antiretroviral Therapy
Objective: to determine adherence of an indigent African HIV-infected cohort initiating antiretroviral therapy (ART); to identify predictors of incomplete adherence (< 95%) and virologic failure (> 400 HIV RNA copies/ml).
Design: Prospective monitoring of adherence in a poor HIV-positive cohort, attending a public sector hospital and receiving ART through phase III studies.
Methods: Adherence to ART was determined over 48 weeks by counting tablet-returns. Logistic regression models including age, WHO HIV stage, home language, socio-economic status, complexity and type of regimen were fitted to determine predictors of incomplete adherence and virologic failure at 48 weeks.
Results: 289 patients were recruited between January 1996 and May 2001. Median (mean) adherence of the cohort was 93.5% (87.2%). Three times daily dosing [risk ratio (RR), 3.07; 95% confidence interval (CI), 1.40-6.74], speaking English (RR, 0.41; 95% CI, 0.21-0.80) and age (RR, 0.97; 95% CI, 0.94-0.99) were independent predictors of incomplete adherence. Socio-economic status, sex and HIV stage did not predict adherence. Independent predictors of virologic failure included baseline viral load (RR, 2.57; 95% CI, 1.57-4.22) and three times daily dosing (RR, 2.64; 95% CI, 1.23-5.66), incomplete adherence (RR, 1.92; 95% CI, 1.10-3.57), age (RR, 0.96; 95% CI, 0.92-0.99) and dual nucleoside therapy (RR, 2.69; 95% CI, 1.17-6.15).
Conclusion: The proportion of individuals achieving viral suppression matched results from the developing world. Speaking the same language as site staff and simplified dosing frequency were beneficial. Socio-economic status had no impact on adherence and should not be used as a limitation to ART access.
The majority of HIV infected individuals live in sub-Saharan Africa. Over 4.7 million people are infected in South Africa alone, approximately one in every five adults. South Africa is a middle-income, developing country and until recently, treatment with antiretroviral therapy (ART) on a large scale was considered financially impossible. In 2001, however, the local pricing of triple ART decreased by approximately 75%, and it is now available for less than $1000 per year. A recent out of court settlement between the government and pharmaceutical industry has further encouraged reduced antiretroviral pricing, which will expand access to South Africans receiving health care in the public sector.
Expectation of poor adherence is a major concern in expanding therapy to South Africans, many of whom live in severe poverty. A spokesman for USAID encapsulated these assumptions with his statement: 'Ask Africans to take their drugs at a certain time of day, and they do not know what you are talking about'. This is concerning because adherence to therapy is a strong predictor of viral load suppression, immune recovery, disease progression, and death. There is also the widely held belief that non-adherence to therapy among sub-Saharan Africans will lead to rapid development and spread of HIV drug resistance. In contrast to current expectations of non-adherence, Laurent et al. reported high levels of adherence in Senegal. As yet there are no published studies of objectively measured adherence in resource-limited settings comprising the majority of HIV infected patients.
We set out to measure pill count adherence and virologic suppression in a cohort of semi-urban South Africans living in extreme poverty.
Objective: to determine adherence of an indigent African HIV-infected cohort initiating antiretroviral therapy (ART); to identify predictors of incomplete adherence (< 95%) and virologic failure (> 400 HIV RNA copies/ml).
Design: Prospective monitoring of adherence in a poor HIV-positive cohort, attending a public sector hospital and receiving ART through phase III studies.
Methods: Adherence to ART was determined over 48 weeks by counting tablet-returns. Logistic regression models including age, WHO HIV stage, home language, socio-economic status, complexity and type of regimen were fitted to determine predictors of incomplete adherence and virologic failure at 48 weeks.
Results: 289 patients were recruited between January 1996 and May 2001. Median (mean) adherence of the cohort was 93.5% (87.2%). Three times daily dosing [risk ratio (RR), 3.07; 95% confidence interval (CI), 1.40-6.74], speaking English (RR, 0.41; 95% CI, 0.21-0.80) and age (RR, 0.97; 95% CI, 0.94-0.99) were independent predictors of incomplete adherence. Socio-economic status, sex and HIV stage did not predict adherence. Independent predictors of virologic failure included baseline viral load (RR, 2.57; 95% CI, 1.57-4.22) and three times daily dosing (RR, 2.64; 95% CI, 1.23-5.66), incomplete adherence (RR, 1.92; 95% CI, 1.10-3.57), age (RR, 0.96; 95% CI, 0.92-0.99) and dual nucleoside therapy (RR, 2.69; 95% CI, 1.17-6.15).
Conclusion: The proportion of individuals achieving viral suppression matched results from the developing world. Speaking the same language as site staff and simplified dosing frequency were beneficial. Socio-economic status had no impact on adherence and should not be used as a limitation to ART access.
The majority of HIV infected individuals live in sub-Saharan Africa. Over 4.7 million people are infected in South Africa alone, approximately one in every five adults. South Africa is a middle-income, developing country and until recently, treatment with antiretroviral therapy (ART) on a large scale was considered financially impossible. In 2001, however, the local pricing of triple ART decreased by approximately 75%, and it is now available for less than $1000 per year. A recent out of court settlement between the government and pharmaceutical industry has further encouraged reduced antiretroviral pricing, which will expand access to South Africans receiving health care in the public sector.
Expectation of poor adherence is a major concern in expanding therapy to South Africans, many of whom live in severe poverty. A spokesman for USAID encapsulated these assumptions with his statement: 'Ask Africans to take their drugs at a certain time of day, and they do not know what you are talking about'. This is concerning because adherence to therapy is a strong predictor of viral load suppression, immune recovery, disease progression, and death. There is also the widely held belief that non-adherence to therapy among sub-Saharan Africans will lead to rapid development and spread of HIV drug resistance. In contrast to current expectations of non-adherence, Laurent et al. reported high levels of adherence in Senegal. As yet there are no published studies of objectively measured adherence in resource-limited settings comprising the majority of HIV infected patients.
We set out to measure pill count adherence and virologic suppression in a cohort of semi-urban South Africans living in extreme poverty.
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