Improving adherence to antiretroviral therapy in sub-Saharan African HIV-positive populations: An enhanced adherence package

Abstract

With the increasing access to antiretroviral therapy in sub-Saharan African HIV-positive populations, it is important to find additional simple, effective, and feasible methods of improving and maintaining adequately high levels of adherence. In this study, we undertook the development, testing, implementation, and evaluation of various adherence support interventions at four sites in Uganda. A one-group pre- and post-intervention design was employed under routine operational conditions. Various adherence support strategies were identified, adapted, and developed. These strategies which included a combination of elements such as counseling, group education, leaflets, late attendee tracing, and adherence diaries was implemented for an antiretroviral treatment cohort which had baseline levels of adherence measured preintervention. Follow-up was from August 2009 through August 2010. Mean adherence and proportions of clients achieving adherence levels of 95% and above were determined at end of follow-up. Of the 967 participants enrolled, 856 (88.5%) completed follow-up. A before-and-after comparison of outcomes demonstrated that mean adherence (95% confidence interval [CI]) improved statistically significant from baseline following implementation of the interventions (97.4% [96.9–97.9%] to 99.1% [99.0–99.3%], P=0.001). There was also a significant difference between proportions with optimal (≥95%) and suboptimal adherence (<95%) pre- and post-intervention (7.0% difference, 95% CI: 4.6–9.4%, P<0.001). We conclude that additional adherence strategies (including counseling, group education, leaflets, late attendee tracing, and adherence diaries) can substantially improve and maintain high levels of treatment adherence in the long term. Health systems in sub-Saharan African countries should consider integrating these elements into their treatment programs for HIV/AIDS.

Keywords:

• adherence
• interventions
• health education
• anti-retroviral therapy
• HIV/AIDS

Acknowledgements

We acknowledge the support of the Ugandan NACP in facilitating this study. We thank the management and health workers of the Kayunga, Jinja, Bukulula, and Lyantonde sites. The study team also acknowledges the invaluable contributions of the Research Assistant, Nicholas Ssendege and the adherence workers namely, Solomy Kataabu, Mayombwe Rashid, Josephine Mirembe, Isaac Buzaka, Loyce Babirye, Nakimera Salamah, Namuwanga Nelly, Oliver Namuddu, Jane Kigongo, and Sarah Mukankundiye. Special thanks to all ART clients and members of the community at all the four sites who willingly participated in the surveys. The project was funded by the Communicable Disease Research Program (COMDIS) Consortium led by the Nuffield Centre at Leeds University which itself is funded by the Department for International Development, UK.

This document is an output from a project funded by UK Aid from the UK Department for International Development (DFID) for the benefit of developing countries. However, the views expressed and information contained in it are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them.

Notes

1. The tabletop flip-chart (Supplementary data file 1) and educational leaflets (Supplementary data file 2) are available as supporting information. To access them, please click the following link, http://www.leeds.ac.uk/lihs/nuffield/publications/2011.html.