Elsevier

The Lancet

Volume 368, Issue 9547, 4–10 November 2006, Pages 1587-1594
The Lancet

Articles
Adherence to antiretroviral therapy in a home-based AIDS care programme in rural Uganda

https://doi.org/10.1016/S0140-6736(06)69118-6Get rights and content

Summary

Background

Poverty and limited health services in rural Africa present barriers to adherence to antiretroviral therapy that necessitate innovative options other than facility-based methods for delivery and monitoring of such therapy. We assessed adherence to antiretroviral therapy in a cohort of HIV-infected people in a home-based AIDS care programme that provides the therapy and other AIDS care, prevention, and support services in rural Uganda.

Methods

HIV-infected individuals with advanced HIV disease or a CD4-cell count of less than 250 cells per μL were eligible for antiretroviral therapy. Adherence interventions included group education, personal adherence plans developed with trained counsellors, a medicine companion, and weekly home delivery of antiretroviral therapy by trained lay field officers. We analysed factors associated with pill count adherence (PCA) of less than 95%, medication possession ratio (MPR) of less than 95%, and HIV viral load of 1000 copies per mL or more at 6 months (second quarter) and 12 months (fourth quarter) of follow-up.

Findings

987 adults who had received no previous antiretroviral therapy (median CD4-cell count 124 cells per μL, median viral load 217 000 copies per mL) were enrolled between July, 2003, and May, 2004. PCA of less than 95% was calculated for 0·7–2·6% of participants in any quarter and MPR of less than 95% for 3·3–11·1%. Viral load was below 1000 copies per mL for 894 (98%) of 913 participants in the second quarter and for 860 (96%) of 894 of participants in the fourth quarter. In separate multivariate models, viral load of at least 1000 copies per mL was associated with both PCA below 95% (second quarter odds ratio 10·6 [95% CI 2·45–45·7]; fourth quarter 14·5 [2·51–83·6]) and MPR less than 95% (second quarter 9·44 [3·40–26·2]; fourth quarter 10·5 [4·22–25·9]).

Interpretation

Good adherence and response to antiretroviral therapy can be achieved in a home-based AIDS care programme in a resource-limited rural African setting. Health-care systems must continue to implement, evaluate, and modify interventions to overcome barriers to comprehensive AIDS care programmes, especially the barriers to adherence with antiretroviral therapy.

Introduction

With the rapid expansion of access to combination antiretroviral therapy in resource-limited countries in Africa, Asia, South America, Central America, and the Caribbean, more people worldwide will have started therapy between 2004 and 2006 than in all the preceding years of the HIV/AIDS epidemic.1, 2, 3 In response to this rapid increase, WHO has promoted a public-health approach to therapy that is standard and simple.4 Among the many benefits of this approach are streamlined education and training about administration, tolerability, and adherence to antiretroviral therapy, which mean that learning about a few drugs is all that is needed. Good adherence to antiretroviral therapy is necessary to achieve the best virological response, lower the risk that drug resistance will develop, and reduce morbidity and mortality.5 However, adherence barriers vary in different settings, and lessons from more developed countries6 need to be adapted to resource-limited settings.7 Good adherence to antiretroviral therapy has been shown in Africa,8, 9, 10, 11, 12, 13, 14 though caution is needed about generalisation based on selective reporting of positive results, which are almost exclusively from urban areas.15

We describe adherence and virological response to antiretroviral therapy within the context of a novel home-based AIDS care programme in rural Uganda. The programme uses trained lay people who regularly visit participants at home to deliver medication and to collect information about adherence to antiretroviral therapy and possible toxic effects. The programme builds on studies of safe drinking water and prophylaxis with co-trimoxazole (trimethoprim and sulfamethoxazole) that lowered morbidity and mortality in the same community.16, 17

Section snippets

Participants

In May, 2003, we began enrolling people in the home-based AIDS care programme in the Tororo and Busia districts of Uganda, a rural area where most people live in thatched houses in small villages. They are mostly subsistence farmers and are without access to municipal water supplies. Individuals eligible to be screened for participation in the project were clients of the AIDS Support Organization (TASO) and lived within a 100 km2 area served by the organisation's regional branch.18 This

Results

Between May, 2003, and December, 2004, 1139 people started antiretroviral therapy in the home-based AIDS care programme. This analysis includes 987 antiretroviral-naïve adults enrolled during their first screening for antiretroviral-therapy eligibility between July 1, 2003, and May 31, 2004 (table 1).

Before learning about the home-based AIDS care programme, 581 (59%) of 987 participants had heard of antiretroviral drugs. At baseline and after initial counselling, 967 (98%) participants believed

Discussion

The comprehensive home-based model of AIDS care used in this rural African setting resulted in excellent retention in care and adherence to antiretroviral therapy in a population with limited access to transportation and health-care services. Good adherence to antiretroviral therapy was associated with suppressed viral load that was sustained in most surviving clients during their first year on antiretroviral therapy. The programme removed the external economic constraints to retention in care

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