Adherence to Antiretroviral Therapy Assessed by Pharrmacy Claims and Survival in HIV-infected South Africans

March 7, 2005

Dear friends:

I copied below an abstract presented at 12th Conference on Retroviral and

Opportunistic Infections.Please note that only 50% had adherence better than

70%.The investigators report that adherence less than 80% is one of the factors

associated with decreased survival ( PI studies in the west actually recommend

adherence greater than 95% ).This is a large study involving almost 8,000

patients.It should be a warning for things to come .Unless all these large-scale

Anti-retroviral programs are organized to include adequate education and

adherence programs, we may wake up to more complex situations. Do you remember

the headlines that proclaimed that Africans show high adherence? They were

little more than tricks to push specific agenda.Comprehensive HIV/AIDS care is

complex anywhere but more so in poor countries.A significant part of the

financial resources should be spent on actual organization of the care system

consistent with the needs.We should come up with a volunteer system which

creates an opportunity to work, learn and teach not only in the cities but also

in the rural health facilities.Spending billons of dollars on drugs and lab

tests, as well as endless conferences in the biggest hotels around the globe

does not help the affected people and those at risk.

AW

www.gap-a.org

Adherence to Antiretroviral Therapy Assessed by Pharrmacy Claims and Survival in

HIV-infected South Africans

Nachega*1,3, M Hislop2, M Lo1, S Omer1, D Dowdy1, L Regensberg2, R

Chaisson1, and G Maartens3

1s Hopkins Univ, Baltimore, MD, USA; 2Aids for AIDS, Cape Town, South

Africa; and 3Univ of Cape Town, South Africa

Background: Adherence to antiretroviral therapy (ART) improves survival after

HIV infection. Our hypothesis is that pharmacy claims predict survival rates in

HIV-infected South African adults.

Methods: We studied 7812 HIV-infected adult South Africans enrolled in a

private-sector HIV/AIDS disease management program and who started

triple-combination therapy between January 1999 and March 2003. ART adherence

was calculated by dividing the number of months that patients has submitted

claims by number of months since commencement of ART. ¦Ö2 analysis and

proportional hazard models were used to identify variables associated with

adherence and survival, respectively. Survival curves were compared between

groups with the log-rank test.

Results: The mean age at ART initiation was 37 ¡À8 years; 4605 patients (56%)

were female and 7554 (96.7%) were black Africans. The mean CD4+ count and log10

HIV viral load at enrollment were 145 ¡À 102 cells/mm3 and 5.1 ¡À 0.7 log10

copies/mL, respectively. ART adherence was > 70% for 3908 patients (50.0%), 40

to70% for 1837 (23.5%) and, < 40% for 2067 (26.46%). Patients with > 70%

adherence were more likely to be females than males (62% vs 38%; p < 0.01), but

age < 40 years and CD4+ count < 200 cells/m3 did not predict mean adherence (p >

0.4). As of March 2003, a total of 718 patients died, yielding a crude mortality

rate of 9.2%. In the multivariate proportional hazard model, a threshold

hazard ratio at ART adherence equal to 80% was identified. The variables

significantly associated with decreased survival were: low ART adherence (<

80%) (relative hazard [RH]), 1.31, confidence interval (CI) 1.19 to1.43); male

gender (RH 1.34, 95%, CI 1.15 to 1.56); age ¡Ý 40 years (RH

1.21, 1.04, to 1.41), baseline CD4+ count < 200 cells/mm3 (RH 3.35, 2.62 to

4.26) and high baseline viral load (RH 1.75, 1.54 to1.98 per log10 increase).

Conclusion: Poor ART adherence as assessed by ART claim data is associated with

decreased survival. Pharmacy claims may be a simple and effective tool for

monitoring adherence as ART programs in sub-Saharan Africa are scaled up.

Reasons for poor adherence in males in our study population need to be explored

further.

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March 8, 2005

As a physician involved in providing care to HIV infected children and some

adults, I agree with Ashenafi completely.

At the ground level, efforts at delivery of comprehensive care to PLWHAs are far

from adequate.

It is amazing that there is so much emphasis on ARVs without the needed training

and elightenment doctors, nurses, pharmacists, social workers, counsellors, home

visitors etc

require to guarantee long term success. In most countries including mine, there

is a complete first line regimen but not 2nd line or when available, they aren't

the appropriate combination.

I am not sure if those responsible for planning and delivery have a idea what a

model of comprehensive patient centred HIV care looks like.

I shiver with fear when I think about what things will be like when we have

widespread primarily and even secondary resistant HIV infections.

ashenafi waktola <awaktola@...> wrote: