Adherence & Retention
Working Paper on HIV/AIDS Care in resource poor settings: Optimizing delivery for adherence
Dear members,
Here are some excerpts that you might find interesting.from a paper that Joia Mukherjee and I worked on.
We would love to hear some feedback from the community on this. The full paper is available for free download in PDF format at this link: http://hbswk.hbs.edu/item/6133.html.
The prevention and treatment of a complex disease such as HIV/AIDS in resource-poor settings presents enormous challenges. Many of the social and economic factors that make populations living in these settings vulnerable to HIV/AIDS such as poverty, malnutrition, and political instability conspire to create barriers to effective care delivery. Understanding how interventions are related to each other and how local socioeconomic factors influence them is critical to effective program design.
The care delivery value chain is a framework that can help conceptualize the organization and structure of care delivery for medical conditions. We applied this framework to HIV/AIDS care in resource-limited settings. Several conclusions arise that can help inform the design of care delivery platforms for HIV/AIDS. In "Optimizing the HIV/AIDS Care Delivery Value Chain" section (page 7), we have outlined some of the suggested best practices. These have not yet been studied in a rigorous fashion; they are informed by the experiences of practitioners in the field and the analysis of successful programs. Two of these practices focus on adherence as copied herein:
*Improving adherence to anti-retroviral therapy improves outcomes and costs*
Current antiretroviral therapies need high rates of patient adherence in order to be effective. Improving adherence delays emergence of drug resistance and improves survival. Since high adherence reduces emergence of viral resistance, which is major cause of treatment failures, the need to switch to high cost second line ART should be reduced in programs with high adherence rates. High adherence rates are clearly associated with improved patient outcomes. [Paterson, DL, Swindells, S, Mohr, J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med 2000;
133:21. Free full text available here: http://www.annals.org/cgi/reprint/133/1/21.pdf; summary for patients: http://www.annals.org/cgi/content/summary/133/1/21]. Activities to improve adherence are high value activities because they improve patient outcomes.
Ensuring adherence is a fundamental activity of an HIV/AIDS treatment program, and not solely a responsibility of the patient. Activities to improve adherence include reducing pill burden, actively managing side effects, and involving family and community members in medication management. [Simoni JM, Frick PA, Pantalone DW, Turner BJ. Antiretroviral adherence interventions: a review of current literature and ongoing studies. Topics in HIV Medicine 11(6) Nov-Dec 2003. Free full text available here: http://www.iasusa.org/pub/topics/2003/issue6/185.pdf]. Programs that have used community health workers to administer directly observed ART have reported high adherence rates.[Farmer P, Léandre F, Mukherjee J, Gupta R, Tarter L, Kim JY. Community-based treatment of advanced HIV disease: introducing DOTHAART (directly observed therapy with highly active antiretroviral therapy). Bull World Health Organ 2001; 79:1145-51. Free full text available here: http://www.pih.org/inforesources/Articles/BullWHO_2001_Farmer-et-al_DOT-HAART.pd
f]
*Management of social and economic barriers is critical to the treatment of
HIV/AIDS*
HIV/AIDS disproportionately affects marginalized and impoverished populations. Patients in resource-poor settings often have limited access to transportation, clean water, safe housing, or reliable food supplies. They can lack adequate educational and economic opportunities. Women and children's rights and agency may be severely limited in some contexts. HIV care is complex and life-long, and these barriers need to be addressed in order for effective care to be delivered. Research suggests that providing multivitamin supplements and ensuring adequate food security can delay progression of AIDS and improve outcomes in malnourished populations.[Free full text available here: Fawzi, WW, Msamanga, GI, Spiegelman, D, et al. A randomized trial of multivitamin supplements and HIV disease progression and mortality. N Engl J Med 2004; 351:23. Free full text available
here: http://content.nejm.org/cgi/content/full/351/1/23]
In addition, the provision of ART without charge has been shown to improve viral suppression in patients.[Ivers LC, Kendrick D, Doucette K. Efficacy of antiretroviral therapy programs in resource-poor settings: a meta-analysis of the published literature. Clin Infect Dis 2005; 41: 217-24. Free full text available here: http://www.journals.uchicago.edu/doi/pdf/10.1086/431199] Despite these findings, many programs continue to charge user-fees despite little data to support their effectiveness. These barriers to care must be understood as part of configuring the care delivery value chain, not outside of it. Activities to reduce these barriers maximize value across the care cycle by encouraging patients' entry into care and by helping to facilitate follow up and retention. To reduce these barriers, programs can waive user fees, and provide services such as transportation and food supplements to the most needy.
K. Rivet Amico, PhD
A great call for the need for integrated intervention/prevention approaches! I would add to this list, strategies to promote risk reduction within cohorts who are positive and other self-care/health protective behaviors (as well noted, adherence to ARVs, but also adherence to other treatment recommendations- e.g., early enrollment into care, retention over time) within the compendium of services to best facilitate use of services as they become available/accessible. Thanks for sharing this work!
6:12 AM, 9 May 2009 | Permalink