Long-Term Adherence to Antiretroviral Treatment and Program Drop-Out in a High-Risk Urban Setting in Sub-Saharan Africa: A Prospective Cohort Study

Abstract

BackgroundSeventy percent of urban populations in sub-Saharan Africa live in slums. Sustaining HIV patients in these high-risk and highly mobile settings is a major future challenge. This study seeks to assess program retention and to find determinants for low adherence to antiretroviral treatment (ART) and drop-out from an established HIV/ART program in Kibera, Nairobi, one of Africa's largest informal urban settlements.Methods and FindingsA prospective open cohort study of 800 patients was performed at the African Medical Research Foundation (AMREF) clinic in the Kibera slum. Adherence to ART and drop-out from the ART program were independent outcomes. Two different adherence measures were used: (1) “dose adherence” (the proportion of a prescribed dose taken over the past 4 days) and (2) “adherence index” (based on three adherence questions covering dosing, timing and special instructions). Drop-out from the program was calculated based on clinic appointment dates and number of prescribed doses, and a patient was defined as being lost to follow-up if over 90 days had expired since the last prescribed dose. More than one third of patients were non-adherent when all three aspects of adherence – dosing, timing and special instructions – were taken into account. Multivariate logistic regression revealed that not disclosing HIV status, having a low level of education, living below the poverty limit (US$ 2/day) and not having a treatment buddy were significant predictors for non-adherence. Additionally, one quarter of patients dropped out for more than 90 days after the last prescribed ART dose. Not having a treatment buddy was associated with increased risk for drop-out (hazard ratio 1.4, 95% CI = 1.0–1.9).ConclusionThese findings point to the dilemma of trying to sustain a growing number of people on life-long ART in conditions where prevailing stigma, poverty and food shortages threatens the long-term success of HIV treatment.

Patient Factors Influencing Adherence to ART Treatment among HIV/AIDS Patients in Embu Teaching and Referral Hospital Comprehensive Care Clinic

“…Adherence to ART is crucial for treatment success among HIV patients‚ high levels of adherence is a prerequisite for maintained viral suppression and lowers risk of drug resistance, this in turn will prevent premature morbidity and mortality [1]. Low adherence is the second strongest determinant for disease deterioration and death after CD4 count.…”

Knowledge and attitudes regarding HIV/AIDS and antiretroviral therapy among patients at a Nigerian treatment clinic

“…Unfortunately, this knowledge about the disease has not resulted in appreciable changes in attitude or in behaviour modifications in the population [7,8]. For example, a study conducted in 2005 by the University of Ibadan, Ibadan, in south-western Nigeria, reported that over 90% of students possessed a good knowledge about HIV/AIDS and its transmission but that only 16.6% of sexually active students who were interviewed used condoms for protection during intercourse in the three months before the study.…”

“…Substantial rates of decline in the number of opportunistic infections and in the prevalence of AIDS-related mortality have been observed [12,13]. A number of studies have reported reductions in the level of plasma HIV-1 RNA and increases in the number of the CD4 cell count, even among PLWHA with very low initial CD4 counts [14][15][16][17][18]. Antiretroviral drugs must be taken as a lifelong therapy and their success relies on continual adherence to the medication regimen.…”

Is Option B+ the best choice?

“…The success of Option B+ depends on the retention of women in treatment programmes, which increases pressure on already strained health systems. [11,12] Recent data show that adequate adherence drops from 75.7% (95% CI: 71.5 -79.7%) during pregnancy to 53% (95% CI 32.8 -72.7) postpartum among women who meet present ART criteria. [13] The public health implications (including resistance and potential for future treatment) of reduced adherence in Options B and especially B+ are unknown and likely to be concerning.…”