Global Implications of HIV Treatment Adherence How can we treat AIDS as a chronic disease

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Global Implications of HIVTreatment Adherence
How can we treat AIDS as a chronic disease?

• Richard Laing
• Policy Access and Rational Use of Medicines Team
• Geneva

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Adherence and ART Therapy

• Treatment outcome is closely related to level of
  adherence (Paterson et al 2000)
• Early adherence more important than later
  adherence (Carrieri 2003)
• If first line therapy fails, deciding when to
  initiate second line therapy is very difficult
  without viral load testing and is 10 more
  expensive

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Adherence and Viral Suppression
trend P0.0081.
Source Oyugi JH et al Treatment interruptions
predict resistance in HIV-positive individuals
purchasing fixed-dose combination antiretroviral
therapy in Kampala, Uganda AIDS 2007,
21965971
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Even with good adherence better adherence leads
to better outcomes
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Source Reynolds et al J Acquir Immune Defic Syndr
Volume 47, Number 1, January 1, 2008
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On hunger, transport costs and waiting time
challenges to ARV adherence in three African
countriesAnita Hardon, University of
AmsterdamSheila Davey, GenevaTrudie Gerrits,
University of AmsterdamCatherine Hodgkin, Royal
Tropical Institute, AmsterdamHenry Irunde,
Principal Investigator, TanzaniaJoyce Kgatlwane,
Principal Investigator, BotswanaAlice
Nakiyemba, Principal Investigator, Uganda John
Kinsman, University of Amsterdam Richard
Laing, WHO Geneva
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Patients' waiting area at Jinja Hospital.
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Quantitative results adherence estimates
Average percentage of doses taken at the right
time in the study population, by adherence
measurement instrument
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Reasons reported for missing medication
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Qualitative results what are the constraints to
optimal adherence

• Transport costs
• User fees
• Waiting times
• Hunger
• Stigma
• Side-effects
• Lack of counselling
• Heavy workloads
• Lack of space for confidential consultations

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Transport costs

• I have very many people in the village, they are
  dying because they dont have money to transport
  themselves to the hospital. You need to have this
  money monthly. (ARV user, Uganda)
• I once missed my appointment for refill because
  there were no vehicles coming here. I was in the
  stop from early morning and by noon I went back
  home. Fortunately I still had some medications.
  (Male ARV user, Botswana).

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Waiting times

• In all three studies, the problem of long
  waiting times was cited as a major challenge to
  adherence.
• In Tanzania, the mean time spent at the clinic
  was six hours.
• In Botswana, most respondents reported that they
  spent around four hours at the clinic.
• In Uganda, the average waiting time for ARV users
  was five hours in the public facility and one
  hour in the private facility.

Botswana
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Costs in Uganda

• Cost in terms of user fees, transport and other
  overhead costs had a very large impact on
  adherence and is likely to affect adherence
• Although all the respondents were receiving
  medicines free of charge, additional costs
  incurred through travel to the facilities and
  user charges at the private facility have
  implications for adherence,
• Sir, I came from very far. Over fifty kilometers
  from here. Before I come to the hospital I have
  to plan the money for journey fare to the clinic.
  In fact my extra drugs got finished yesterday.
  (Male ARV user, JRRH)
• I can no longer pay school fees for my children
  because I am burdened by extra costs of
  maintaining my health. (Male ARV user, FGD)

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Hunger

• The problem I have with ARVs is related to food.
  I have no money and ARVs increase appetite. I am
  not capable of buying food. (Male ARV user,
  Tanzania)
• Majority of people say the ARV treatment makes
  them to eat a lot. Some quit the treatment
  because they complain about the lack of food.
  (FGD participant, Botswana)
• Some patients have expressed lack of food as a
  reason for not wanting to swallow the life-saving
  drugs. In fact we have one woman who has declined
  her life-saving drugs because she does not have
  enough food to feed herself. (Doctor, NTC
  Uganda)

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Stigma

• Some examples
• Job loss (Tanzania)
• Abandonment or badly treated by partners
  (Botswana)
• Isolated by community members (Uganda)
• Fearing such stigmatization, ARV users often
  decide to hide their HIV status.
• I cannot take my drugs when people are seeing. I
  always go and hide when I take them. Otherwise,
  people start whispering about you all the time.
  (ARV user, female FGD, Uganda)
• I usually miss my medications when I visit
  friends because I have not told them about my HIV
  and so I do not want them to see my medications.
  (Male ARV user, Botswana)

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Lack of counselling .. And heavy workloads

• You find 25 patients and only one person
  attending all these patients and he just tells
  you to go and collect your medication." (Male FGD
  participant, Tanzania)
• You overwork like this without even a break
  because there are too many people all coming one
  day and yet you are very few. (Health care
  worker FGD, Uganda)

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Recommendations

• Encourage small-scale studies using a
  combination of qualitative and quantitative rapid
  assessment tools (conducted by local researchers
  in collaboration with front-line health workers)
  to
• Estimate adherence levels using multiple methods
• Identify factors that facilitate or constrain
  adherence
• Indicate possible solutions
• Evaluate innovative adherence support measures
  such as
• Scheduling
• Food supplementation
• Transport vouchers
• Community support mechanisms
• Treatment continuation points
• Cell phone support
• Etc, etc, etc

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Conclusion Chronic Diseases

• With the dramatic improvement in ARV availability
  and the rapid scaling up of ART therapy there
  will inevitably be more requests for assistance
  related to adherence
• Considerable experience about adherence for
  chronic diseases exists in developed countries
• Chronic diseases are different from acute
  diseases
• Not emergencies
• Experienced and expert patients
• Predictable appointments
• Need long term record keeping with performance
  monitoring
• Long term supply requirements
• Patients move and change
• If we fail to address adherence seriously we will
  inevitably face major treatment failures and
  transmission of resistant virus

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Questions for Future?

• How can we change programmes to accommodate
  special needs of AIDS and other chronic disease
  patients?
• Is the number of patients enrolled or the number
  of patients still on treatment the key statistic?
• How can adherence support be provided to all AIDS
  patients on treatment?
• When will we measure adherence at an individual
  and facility level?
• When will we provide an equal level of support
  for adherence as we do for access to ARV's?