BackgroundAccess to antiretroviral therapy has dramatically expanded in Africa in recent years, but there are no validated approaches to measure treatment adherence in these settings.MethodsIn 16 health facilities, we observed a retrospective cohort of patients initiating antiretroviral therapy. We constructed eight indicators of adherence and visit attendance during the first 18 months of treatment from data in clinic and pharmacy records and attendance logs. We measured the correlation among these measures and assessed how well each predicted changes in weight and CD4 count.ResultsWe followed 488 patients; 63.5% had 100% coverage of medicines during follow-up; 2.7% experienced a 30-day gap in treatment; 72.6% self-reported perfect adherence in all clinic visits; and 19.9% missed multiple clinic visits. After six months of treatment, mean weight gain was 3.9 kg and mean increase in CD4 count was 138.1 cells/mm3.Dispensing-based adherence, self-reported adherence, and consistent visit attendance were highly correlated. The first two types of adherence measure predicted gains in weight and CD4 count; consistent visit attendance was associated only with weight gain.ConclusionsThis study demonstrates that routine data in African health facilities can be used to monitor antiretroviral adherence at the patient and system level.
BackgroundAn 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.MethodsTargeting 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.ResultsIn 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.ConclusionsField 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.
Objective. To describe the development, implementation, and initial outcomes of a pharmaceutical care training-of-trainers course developed to assist Ethiopian pharmacy faculty members and graduate students in the development of curriculum and provision of pharmaceutical care services of relevance to this low-income country. Design. In this collaboration, US and Ethiopian faculty members worked together in a week-long seminar and in hospital ward rounds to develop and offer a course to facilitate faculty members, curricular, and service development in pharmaceutical care in Ethiopia. Assessment. Assessments were conducted during the seminar, immediately post-seminar, at 3 months post-seminar, and at 1 year post-seminar. An examination was administered at the conclusion of the course to assess immediate learning outcomes for the graduate students. Post-course assessments of short-term (3-month) and longer-term (12-month) impact were conducted to identify pharmaceutical care services that had been implemented to assess knowledge and skill gained during the seminar. Correspondence between seminar participants and the US faculty members as well as graduate student thesis projects provided further evidence of changes at 3 and 12 months post-course. Conclusion. Pharmaceutical care training was developed for Ethiopian faculty members through a seminar and hospital ward rounds. Enhancements have been added to curricula for bachelor in pharmacy students and select pharmaceutical care services have been implemented through master's thesis projects.
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