Evaluating adherence to highly active antiretroviral therapy with use of pill counts and viral load measurement in the drug resources enhancement against AIDS and malnutrition program in Mozambique
ABSTRACT Maintaining treatment adherence among the growing number of patients receiving antiretroviral treatment in Africa is a dramatic challenge. The objective of our study was to explore the results of a computerized pill count method and to test the validity, sensitivity, and specificity of this method with respect to viral load measurement in an African setting.
We performed a prospective, observational study involving patients who received first-line highly active antiretroviral therapy in Mozambique from 1 April 2005 through 31 March 2006. Enrolled patients had received treatment for at least 3 months before the study. For defining treatment adherence levels, pill counts were used, and the results were analyzed with viral load measurements at the end of the observation period.
The study involved 531 participants. During the 12 months of observation, 137 patients left the program or discontinued first-line therapy. Of the remaining 394 patients, 284 (72.1%) had >95% treatment adherence; of those 284 patients, 274 (96.5%) had a final viral load <1000 copies/mL. A Cox proportional hazards analysis revealed that the relationship between >95% treatment adherence and the final viral load was closer than that between >90% treatment adherence and viral load.
Treatment adherence >95% maximizes the results of the nonnucleoside reverse-transcriptase inhibitor-based regimen. The pill count method appears to be a reliable and economic tool for monitoring treatment adherence in resource-limited settings.
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ABSTRACT: The rapid scale-up of HIV care and treatment in Mozambique has provided an opportunity to reach people living with HIV (PLHIV) with prevention interventions in HIV care and treatment settings. A three-day Positive Prevention (PP) training intervention for health care providers that focused on pressing issues for PLHIV in Mozambique was adapted and delivered at sites in three provinces. In-depth interviews were conducted with 31 providers trained in the PP curriculum. Qualitative data were used to assess the appropriateness of the training materials and approach, which lessons providers learned and were able to implement and which PP messages were still difficult to deliver. Providers reported gaining numerous insights from the training, including how to conduct a risk assessment and client-centered counseling, negotiating disclosure, partner testing, condom use, PMTCT, treatment adherence and approaches for positive living. Training topics not commonly mentioned included discordance counseling, STIs, family planning, alcohol and drug use, and frank sexual risk discussions. While areas for improvement exist, the PP training was useful in transferring skills to providers and is a viable component of HIV care. This evaluation helps identify areas where future PP trainings and specific strategies and messages can be refined for the Mozambican context.Evaluation and program planning 11/2013; 43C:38-47. DOI:10.1016/j.evalprogplan.2013.10.006 · 0.89 Impact Factor
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ABSTRACT: HIV-infected children have less access to combination antiretrovirals (cART) as compared to adults in resource-limited settings. Growth faltering, loss to follow-up (LTFU) and high mortality are frequently seen. A retrospective cohort study was performed with parameters extracted from the DREAM database for HIV-infected, antiretroviral naïve children under 15 years presenting for care at 17 DREAM centers in Mozambique, Malawi and Guinea between 01/2005 to 12/2008. Predictors of time-to-death, time-to-LTFU and persistence of malnutrition by Cox's regression and Kaplan Meier were determined. 2215 children presented to care with 1343 (61%) being < 5 years. At baseline stunting and malnutrition occurred in 40% and 25% respectively; 75% of 2149 children had CD4 cell percentages less than 20; median HIV RNA, log10 cp/ml was 4.97 in 1927 patients. Over time 238 children died (10.7%; 2.7% PY); 63 were LTFU (2.8%; 0.7% PY). By multivariate analysis mortality was associated with virus load (HR: 1.19; CI: 1.01-1.402, p = 0.038) and reduced weight-for-age-Z-scores (WAZ) (HR: 0.590; CI: 0.53-0.66, p < 0.001). LTFU was associated with low weight-for-height-Z-scores (WHZ) (HR: 0.71; CI: 0.51-0.97, p = 0.031). At 12 mo following cART, anthropometric parameters significantly improved in 1226 children (p< 0.001); virus load declined to < 400 copies/ml in over 60%. Despite advanced HIV disease, children initiating cART had mortality rates of 2.7% p/PY with overall attrition rates of 11.7% p/100 PY, with significant reversal of negative anthropometric markers, and improvement of immunological and virological parameters in children with 12 months of follow-up.The Pediatric Infectious Disease Journal 06/2013; 33(3). DOI:10.1097/INF.0b013e3182a0994b · 3.14 Impact Factor
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ABSTRACT: Background: ART is a life long treatment and its effectiveness depends critically both on the efficacy of the antiretroviral drugs against the virus, and achieving a very high level of adherence (> 95 %) to the medications. Adherence poses a special challenge and requires commitment from the patient and the health care provider. Objectives: The study evaluated medication adherence, and identified risk factors for non-adherence in HIV-infected ART patients. Methods: In a cross-sectional survey, medication adherence of 118 HIV-infected ART patients who received pretreatment and ongoing adherence counseling and education for 6 months was evaluated using a self-administered studyspecific 16-item questionnaire. Self-reported adherence was calculated as the mean of patients' adherence to the medication schedule and the number of prescribed doses of medications missed. Chi-square statistics was used to test the association of adherence with occupation and education at 95 % CI. Results: The mean age of participants was 33.9 (95 % CI, 29.6-38.2) years; and 82.2 % of participants were aged 26-45years; 60.2 % females, 80.5 % attained secondary education at the least; and 77.1 % were employed. All participants reported been counseled on the benefits of ART and medication adherence at ART initiation. On assessment of participants' knowledge of the benefits of ART and medication adherence, 92.2 % were very knowledgeable, 2.9 % reported wrongly that ART is a cure for HIV. The self-reported adherence to medication schedule was 68.9 % (range: 0 % - 100 %), of which 83 (70.3 %) reported > 75 % adherence; while adherence to prescribed doses of medications was 89.2 % (range: 20 % - 100 %), of which 100 (84.7 %) participants reported > 80 % adherence. Mean self-reported adherence (±SD) was 79.1 % ± 14.4 %. Employment status was associated with poor adherence (P < 0.05), unlike the educational status. The major reasons reported for non-adherence were busy at work or school (33.1 %), forgetfulness (15.5 %), fasting (12.0 %), and travelled away from home (10.6%). Conclusion: The self-reported adherence was relatively poor compared to the desired value of > 95%. Employment status was associated with poor adherence and this may be corroborated by the major reason reported for non-adherence (busy at work or school). Routine adherence monitoring and multiple adherence interventions in clinical practice are recommended.