Adherence & Retention
Rapid Scale-Up of HIV Care and Treatment Services in Zambia: A Challenge to ART Adherence and Retention in Care
This presentation by Dr. Jeffrey Stringer - Director and CEO of UAB Centre for Infectious Disease Research in Zambia (CIDRZ) - was given at the IAPAC conference in March 2008 and highlights experiences from the scaling up of HIV care and treatment services in Lusaka, Zambia. The presentation focuses on ART adherence and retention in care.
Background
In 2004, The Zambian Ministry of Health began a major scaling-up of HIV/AIDS care and treatment services at primary care clinics in Lusaka, using predominately non-physician clinicians (nurses, clinical officers, pharmacy technicians).
- Adult (15-49) HIV prevalence in Lusaka: 22%
- Estimated # of HIV-infected: 267,900
- All services free (funded by PEPFAR, GFATM, Zambian MoH)
Methods
The adherence analysis was limited to adults in Lusaka, Zambia, who had been on ART for at least one year.
- 18,627 patients included in study
- Adherence defined by pharmacy pick-up (Optimal ≥95%, Suboptimal 80-94%, Poor < 80%)
- Patients were categorized by adherence behavior during the first year of ART and outcomes were evaluated at 12 months.
Results
- Among adults who survived at least 12 months, 91% had above 80% adherence rate.
- Mortality risk was similar between patients in the suboptimal and optimal adherence groups (0.7 – 1.2, adjusted for age, sex, CD4 count, WHO stage, hemoglobin, BMI and presence of adherence “buddy”), and risk in the poor group was approximately double (1.4 – 2.9, adjusted) that of the optimal group.
- Mortality is highest early (<90 days)
- Of 18,627 total patients, 1,348 had a missed visit. After an active follow-up program, it was found that 27% of the patients who missed a visit had died, and another 35% remained untraceable.
Discussion
Challenges:
- Drug supply, forecasting, logistics
- Clinical care capacity and training of local staff
- Iatrogenic complications
o Anemia
o Peripheral neuropathy
o Immune reconstruction syndrome
- Staff and staff burn out
- Space
- Differential response of drug regimens to inadherence
Strategies to Improve Retention:
- Support groups
- Community strategies
- Nutritional support
- Improving clinic experience
o Waiting times
o Supportive services
o Child friendly
Conclusions
- Massive ART scale-up is feasible in resource-limited settings
- Good outcomes can be expected
- Adherence to therapy is generally good
- Retention in care is an increasingly important issue and demands urgent further attention
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