Unpacking issues of adherence: moving beyond access

Abstract

With HIV/AIDS being recognised as a chronic disease, the success of treatment depends on at least 95% adherence rates. In addition, as efforts are implemented to improve comprehensive access to care, treatment and management of the disease, factors influencing adherence play a crucial role in preventing drug resistance. One of the objectives of an overall study on ARV delivery models in SA was to understand factors influencing adherence to ARVs, in urban as well as resource poor settings. Different tools to measure adherence on patients who have been on ARVs for a minimum of 6 months was aimed at providing empirical evidence on the extent of adherence problems through population data (quantitative); as well as why patients may not adhere (qualitative). Medication adherence is measured by patients themselves, through the method of 4 day dosing recall, including possible reasons as to why a dose may have been missed. Semi-structured questionnaires were used to explore other indirect factors which could influence adherence rates negatively. From the patient perspective, these factors range from socio-demographic profiles, alcohol and drug use, waiting times, level of social support, cost to access care and treatment, to clinical biomarkers providing a comprehensive medical history of individual patients, including first line and second line treatment regimes. From the provider perspective, the level of resources available as well as strategies adopted for patient monitoring is assessed. Human resource capacity is assessed in each facility - especially the availability of pharmacists and counsellors who are critical in adherence counselling, patient monitoring and quality service - while lack of adequate physical space would compromise confidentiality and deter patients from adequate follow-up. In SA, where ARVs are free at point of access, cost to both the provider as well as the patient to access continued care, provide further challenges in ensuring long term treatment and management of the disease. Results of this study, show a 97.5% level of adherence to ARV medication. This is further supported by a mean improvement in CD4 count from 128.9 at start of programme to 322.37 recently. However, an analysis of indirect factors impacting on adherence point to placing increased attention on strengthening health systems and finding creative solutions to improve adherence. This should be aimed at both health care facilities as well as support networks within communities. It calls for coordinated efforts from other actors, especially those experienced in chronic care models. If the SA government is aiming at scaling up access to the 1.4 million people that need treatment by 2009, issues of adherence and current lessons need to be addressed urgently to prevent long term treatment failure and future drug resistance.