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