Antiretroviral therapy in resource-poor settings.Decreasing barriers to access and promoting adherence

Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
JAIDS Journal of Acquired Immune Deficiency Syndromes (Impact Factor: 4.56). 01/2007; 43 Suppl 1(Suppl 1):S123-6. DOI: 10.1097/01.qai.0000248348.25630.74
Source: PubMed


Since 2002, the HIV Equity Initiative of the nongovernmental organization Partners in Health has been expanded in conjunction with the Haitian MOH to cover 7 public clinics. More than 8000 HIV-positive persons, 2300 of whom are on antiretroviral therapy (ART) are now followed. This article describes the interventions to promote access to care and adherence to ART developed in reference to the specific context of poverty in rural Haiti. User fees for clinic attendance have been waived for all patients with HIV and tuberculosis and for women presenting for prenatal services. Additionally, HIV testing has been integrated into the provision of primary care services to increase HIV case finding among those presenting to clinic because of illness, rather than solely focusing on those who present for voluntary counseling and testing (VCT). Once a patient is diagnosed with HIV, medications and monitoring tests are provided free of charge and transportation costs for follow-up appointments are covered to defray patients' out-of-pocket expenses. Patients are given home-based adherence support from a network of health workers who provide psychosocial support and directly observed therapy. In addition, the neediest patients receive nutritional support. Following the description of the program is an approximation of the costs of these interventions and a discussion of their impact.

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    • "The phenomenon of perceived medical benefit as a driver for heath seeking behavior with regard to HIV prevention, care and treatment is highlighted by several similar studies [9, 15, 16].Although not exclusive on its own, the importance or anticipated benefit of an individual undergoing a certain procedure is central to health seeking behavior [17–20]. Providing sufficient information to the masses about the importance of VMMC would therefore be a very important incentive to clients as a motivator for health seeking which should be considered both in the short and long term, since it has been found to be useful in other similar settings [13, 21, 22]. The information, however, must clearly spell out that circumcision does not give 100% prevention against HIV acquisition but is a compliment to other HIV prevention strategies. "
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    ABSTRACT: Although voluntary medical male circumcision (VMMC) in Iganga district was launched in 2010 as part of the Uganda national strategy to prevent new HIV infections with a target of having 129,896 eligible males circumcised by 2012, only 35,000 (27%) of the anticipated target had been circumcised by mid 2012. There was paucity of information on why uptake of VMMC was low in this setting where HIV awareness is presumably high. This study sought to understand motivators for uptake of VMMC from the perspective of the clients themselves in order to advocate for feasible approaches to expanding uptake of VMMC in Iganga district and similar settings. In Iganga district, we conducted seven key informant interviews with staff who work in the VMMC clinics and twenty in-depth interviews with clients who had accepted and undergone VMMC. Ten focus-group discussions including a total of 112 participants were also conducted with clients who had undergone VMMC. MOTIVATORS FOR UPTAKE OF VMMC IN THE PERSPECTIVE OF THE CIRCUMCISED CLIENTS AND THE HEALTH CARE STAFF INCLUDED: perceived medical benefit to those circumcised such as protection against acquiring HIV and other sexually transmitted diseases, peer/partner influence, sexual satisfaction and safety and cost to access the service. Since perceived medical benefit was a motivator for seeking VMMC, it can be used to strengthen campaigns for increasing uptake of VMMC. Peer influence could also be used in advocacy campaigns for VMMC expansion, especially using peers who have already undergone VMMC. There is need to ensure that safety and cost to access the service is affordable especially to rural poor as it was mentioned as a motivator for seeking VMMC.
    Full-text · Article · Aug 2013 · Pan African Medical Journal
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    • "Almost all selected studies reported an unambiguous positive impact of community support on a wide range of aspects of the ART programme. First of all, a number of studies indicated that community support can aid in expanding the access to and increasing the coverage of ART programmes in resource-limited settings [23,27,37,38,40,42,43,51,55]. In addition, the services provided by these community support initiatives have been shown to increase adherence levels[41,49-51,54-58]. "
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    ABSTRACT: Task-shifting to lay community health providers is increasingly suggested as a potential strategy to overcome the barriers to sustainable antiretroviral treatment (ART) scale-up in high-HIV-prevalence, resource-limited settings. The dearth of systematic scientific evidence on the contributory role and function of these forms of community mobilisation has rendered a formal evaluation of the published results of existing community support programmes a research priority. We reviewed the relevant published work for the period from November 2003 to December 2011 in accordance with the guidelines for a synthetic review. ISI Web of Knowledge, Science Direct, BioMed Central, OVID Medline, PubMed, Social Services Abstracts, and Sociological Abstracts and a number of relevant websites were searched. The reviewed literature reported an unambiguous positive impact of community support on a wide range of aspects, including access, coverage, adherence, virological and immunological outcomes, patient retention and survival. Looking at the mechanisms through which community support can impact ART programmes, the review indicates that community support initiatives are a promising strategy to address five often cited challenges to ART scale-up, namely (1) the lack of integration of ART services into the general health system; (2) the growing need for comprehensive care, (3) patient empowerment, (4) and defaulter tracing; and (5) the crippling shortage in human resources for health. The literature indicates that by linking HIV/AIDS-care to other primary health care programmes, by providing psychosocial care in addition to the technical-medical care from nurses and doctors, by empowering patients towards self-management and by tracing defaulters, well-organised community support initiatives are a vital part of any sustainable public-sector ART programme. The review demonstrates that community support initiatives are a potentially effective strategy to address the growing shortage of health workers, and to broaden care to accommodate the needs associated with chronic HIV/AIDS. The existing evidence suggests that community support programmes, although not necessarily cheap or easy, remain a good investment to improve coverage of communities with much needed health services, such as ART. For this reason, health policy makers, managers, and providers must acknowledge and strengthen the role of community support in the fight against HIV/AIDS.
    Full-text · Article · Jul 2012 · BMC Health Services Research
    • "Resource-limited settings present unique challenges to ART adherence.[14] Mukherjee et al.,[14] showed that a multitude of structural barriers prevent access to health care and the regular supply of antiretroviral drugs. "
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    ABSTRACT: To benefit from therapy and to avoid contracting treatment resistant strains, the individuals must adhere to medications. The study was designed to assess the degree of drug adherence and its determinants in patients living with HIV/AIDS and TB comorbidity. A cross-sectional study was conducted to assess the degree of drug adherence and its determinants with the help of self-administered questionnaires in Tercha District Hospital in South Ethiopia. A total of 24 patients were included in the study. The majority were females (54.2%) and the mean age was 32.4 (SD±9.6) years. Adherence level was 95.8% for Antiretroviral (ARV) medications and 79.2% for anti TB medications. Educational status was associated with anti TB (P=0.021) medication adherence. The reason for the missed doses were mostly lack of money for transport (23.7% for antiretroviral therapy (ART), 26.0% for TB treatment) and forgetting to take medications (18.4% for ART, 17.4% for TB treatment. The adherence level obtained for both ARV and anti-TB where high. Transportation costs for patients could be reduced by bringing the services close to where they live.
    No preview · Article · Feb 2012 · North American Journal of Medical Sciences
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