Article

Measuring adherence to antiretroviral treatment in resource poor settings: The feasibility of collecting routine data for key indicators

Center for Pharmaceutical Management, Management Sciences for Health, Arlington Virginia, USA.
BMC Health Services Research (Impact Factor: 1.71). 02/2010; 10(43):43. DOI: 10.1186/1472-6963-10-43
Source: PubMed

ABSTRACT

An East African survey showed that among the few health facilities that measured adherence to antiretroviral therapy, practices and definitions varied widely. We evaluated the feasibility of collecting routine data to standardize adherence measurement using a draft set of indicators.
Targeting 20 facilities each in Ethiopia, Kenya, Rwanda, and Uganda, in each facility we interviewed up to 30 patients, examined 100 patient records, and interviewed staff.
In 78 facilities, we interviewed a total of 1,631 patients and reviewed 8,282 records. Difficulties in retrieving records prevented data collection in two facilities. Overall, 94.2% of patients reported perfect adherence; dispensed medicine covered 91.1% of days in a six month retrospective period; 13.7% of patients had a gap of more than 30 days in their dispensed medication; 75.8% of patients attended clinic on or before the date of their next appointment; and 87.1% of patients attended within 3 days.In each of the four countries, the facility-specific median indicators ranged from: 97%-100% for perfect self-reported adherence, 90%-95% of days covered by dispensed medicines, 2%-19% of patients with treatment gaps of 30 days or more, and 72%-91% of appointments attended on time. Individual facilities varied considerably.The percentages of days covered by dispensed medicine, patients with more than 95% of days covered, and patients with a gap of 30 days or more were all significantly correlated with the percentages of patients who attended their appointments on time, within 3 days, or within 30 days of their appointment. Self reported recent adherence in exit interviews was significantly correlated only with the percentage of patients who attended within 3 days of their appointment.
Field tests showed that data to measure adherence can be collected systematically from health facilities in resource-poor settings. The clinical validity of these indicators is assessed in a companion article. Most patients and facilities showed high levels of adherence; however, poor levels of performance in some facilities provide a target for quality improvement efforts.

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    • "Patients need to attend appointments consistently to manage clinical issues related to ART and to avoid gaps in therapy [3], and coming to the clinic regularly has been significantly associated with optimum medication adherence [19]. Patients’ failure to attend the clinic when expected is an objective indicator that is easy to ascertain [9]; inconsistent attendance can identify patients requiring more focused interventions such as adherence counselling or outreach [16]. "
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    ABSTRACT: Achieving high rates of adherence to antiretroviral therapy (ART) in resource-poor settings comprises serious, but different, challenges in both the first months of treatment and during the life-long maintenance phase. We measured the impact of a health system-oriented, facility-based intervention to improve clinic attendance and patient adherence. This was a quasi-experimental, longitudinal, controlled intervention study using interrupted time series analysis. The intervention consisted of (1) using a clinic appointment diary to track patient attendance and monitor monthly performance; (2) changing the mode of asking for self-reported adherence; (3) training staff on adherence concepts, intervention methods, and use of monitoring data; (4) conducting visits to support facility teams with the implementation.We conducted the study in 12 rural district hospitals (6 intervention, 6 control) in Kenya and randomly selected 1894 adult patients over 18 years of age in two cohorts: experienced patients on treatment for at least one year, and newly treated patients initiating ART during the study. Outcome measures were: attending the clinic on or before the date of a scheduled appointment, attending within 3 days of a scheduled appointment, reporting perfect adherence, and experiencing a gap in medication supply of more than 14 days. Among experienced patients, the percentage attending the clinic on or before a scheduled appointment increased in both level (average total increase immediately after intervention) (+5.7%; 95% CI = 2.1, 9.3) and trend (increase per month) (+1.0% per month; 95% CI = 0.6, 1.5) following the intervention, as did the level and trend of those keeping appointments within three days (+4.2%; 95% CI = 1.6, 6.7; and +0.8% per month; 95% CI = 0.6, 1.1, respectively). The relative difference between the intervention and control groups based on the monthly difference in visit rates increased significantly in both level (+6.5; 95% CI = 1.4, 11.6) and trend (1.0% per month; 95% CI = 0.2, 1.8) following the intervention for experienced patients attending the clinic within 3 days of their scheduled appointments.The decrease in the percentage of experienced patients with a medication gap greater than 14 days approached statistical significance (-11.3%; 95% CI = -22.7, 0.1), and the change seemed to persist over 11 months after the intervention. All facility staff used appointment-keeping data to calculate adherence and discussed outcomes regularly. The appointment-tracking system and monthly performance monitoring was strengthened, and patient attendance was improved. Scale-up to national level may be considered.
    Full-text · Article · Jul 2013 · BMC Health Services Research
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    • "This study evaluated medication adherence and its association with CD4 cells response among HIV-positive patients receiving ART. The study reported mean adherence level (83.4%) that is below the required >95% necessary to achieve the goals of ART (Chalker et al., 2010; Arnsten et al., 2001; Paterson et al., 2000). This is similar to previous reports in Nigeria (Mukhtar et al., 2006; Olowookere et al., 2008; Agu et al., 2011). "
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    ABSTRACT: This study evaluated medication adherence following interventions and its association with cluster of differentiation 4 (CD4) cells response among patients receiving antiretroviral therapy (ART) in Specialist Hospital Sokoto, North Western Nigeria. Longitudinal study design was used. Interventions included training of health workers on adherence counseling; pre- and post-ART adherence counseling were provided to patients. Out of 1300 patients on ART who were provided interventions, 365 patients were selected using simple random technique. The CD4-cell measurements at months 0, 6, 12, 18 and 24 were extracted from the patients’ hospital records; and announced pill counts were conducted. Chi square was used to test the association between groups of variables; and P < 0.05 indicated statistical significance. Out of 365 participants sampled, data from 297 (81.4%) participants were valid for analysis. The mean age of participants was 34.7 (95%CI, 33.6 to 35.8) years; 60.9% were females and 76.4% received Zidovudine/Lamivudine/Nevirapine (AZT/3TC/NVP) regimen. The mean percent adherence was 83.4% (95%CI, 80.8% to 86.0%). The mean CD4-cells count (cells/mm3) at ART initiation increased from 198.9 (95%CI, 180.7 to 217.1) to 396.5 (95%CI, 368.3 to 424.7) at 6 months, 428.0 (95%CI, 400.4 to 455.6) at 12 months, 427.2 (95%CI, 405.6 to 448.8) at 18 months, and 501.4 (95%CI, 469.5 to 533.3) at 24 months. This increase was statistically significant (P< 0.05). Participants’ employment and educational status, age, sex and type of ART regimens received had no significant association with medication adherence (P > 0.05). This study reported a mean adherence level that is below the required >95% necessary to achieve the goals of ART. The increase in CD4 cells count over the observation period was statistically significant at the estimated adherence level. Better immunologic outcomes may be achieved with higher adherence level.
    Full-text · Article · May 2013
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    • "This study evaluated medication adherence and its association with CD4 cells response among HIV-positive patients receiving ART. The study reported mean adherence level (83.4%) that is below the required >95% necessary to achieve the goals of ART (Chalker et al., 2010; Arnsten et al., 2001; Paterson et al., 2000). This is similar to previous reports in Nigeria (Mukhtar et al., 2006; Olowookere et al., 2008; Agu et al., 2011). "

    Full-text · Article · May 2013 · Value in Health
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