Patient Experiences In Antiretroviral Therapy Programmes In Kwazulu-Natal, South Africa

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Health Systems Trust

This report presents the methods and findings of a qualitative study of the experiences of patients taking medication for HIV infection as part of an antiretroviral therapy (ART) programme in five sites in KwaZulu-Natal (KZN), South Africa. The study, known as the ADHERE Project, was designed by MEASURE Evaluation and implemented in collaboration with Health Systems Trust to provide information to the KwaZulu-Natal Department of Health for use in expanding and improving their ART services.

Seeing pill-swallowing no TB cure

Directly observed therapy (DOT) -- a controversial technique in which health care workers or community volunteers watch patients swallow tablets -- does not have a significant impact on tuberculosis patients, according to a new report from The Cochrane Library. Still, DOT remains a central tenet of international recommendations for curbing the spread of treatment-resistant bacteria, and experts say they are unconvinced that cliniciansshould abandon the technique.

International Conference on Improving Use of Medicines (ICIUM2004)

ICIUM2004 focuses on some of today's key issues in use of medicines globally, including: access and price; improving use of medicines in the private sector; effects of health sector reform and decentralization on use; implications of TRIPS and globalization for appropriate use of medicines; relationships between use, adherence, and resistance. Researchers, national and international policy makers, clinicians, and others working on medicines issues in specific areas (including access to medicines, HIV/AIDS, malaria, tuberculosis, child health, adult health, and antimicrobial resistance) will come together to exchange experiences and ideas across their specialized fields of interest . ICIUM2004 is structured so that participants may synthesize experiences within and across these different areas.

ZAMBIA: Feature on fear over HIV drug resistance

Zambian health officials have warned of the emergence of strains of the HI virus that are resistant to current antiretroviral (ARV) drug treatment. Dr Ben Chirwa, director general of the Central Board of Health, said a recent laboratory study conducted at the University Teaching Hospital in the capital, Lusaka, had confirmed the drug-resistant strain, and its emergence was clearly an indication that people are not being consistent with their medication. AIDS expert and former health minister, professor Nkandu Luo, told PlusNews the problem was immediate and urgent because of its implications for drug policies and the cost of health care. Last year the government responded to the high cost of ARVs - around US $250 per month - by introducing heavily subsidised medication through the public health system for 10,000 HIV-positive people, at around $8 a month. In Chipata, one of the poorest areas in eastern Zambia, the challenge of resistant strains appears especially alarming, as information on drug adherence and compliance is often not provided by health officials. The community mainly comprises poor subsistence farmers, deeply rooted in a culture of polygamy and early marriages, with an HIV infection rate of 16.8 percent (compared to the national average of 19 percent). Daniel Musoka, 43, a former supervisor at a major bank, was on ARVs for three years, paid for by his employer. When he was retrenched in 1999, as per its policy, the bank paid for only one more year of his treatment. He moved to his father's village in Chipata and continued to buy medicine with his retirement benefits, but the money ran out last year. I had been off treatment for almost eight months. I had an idea about the dangers of stopping treatment, but I did not believe it could be that serious. Musoka has tuberculosis and is not responding well to treatment - the doctors have told him he has developed resistance to the medication and are now experimenting with various ARV combinations. I am bitter that I face death because of a measly 50 [US] dollars (the cost of his monthly treatment), he told PlusNews. He feels the government should institute some kind of medical scheme for people on ARVs, so that they do not jeopardise their lives further by stopping treatment. He blames medical workers, too, for not emphasising the importance of continuity and the consequences of stopping medication. Musoka's health care provider, Nomsa Chembe, says some of her patients who cannot afford to buy their medicines from private chemists or pharmacies have, after a pause in treatment, switched to the cheaper government-supplied drugs provided by clinics and hospitals, with catastrophic results. She suggested better collaboration and a uniform procurement policy for ARVs between the government and private pharmacies, to avoid problems such as Musoka's. Chembe maintains that health workers provide adequate information on compliance and adherence, just as they are trained to do. Patients are told to take their medicines at regular times, eat before taking their doses, and drink at least three litres of water a day to hydrate the body because the medicines are strong. But the reality is that many patients forget to take their doses, thereby confusing their regimen, and find it difficult to access clean drinking water, Chembe said. Most areas are serviced by wells which do not always have fresh water. Food is also a problem - many people can only afford to eat once a day, Chembe noted. Initially, Chembe's clinic gave out packets of high-energy protein (HEP) mix with the medication, but stopped not only because the HEP donations ran out, but entire families of seven or eight began to depend on the 5 kg mix for sustenance, leaving the patient with little or nothing to eat. In the meantime, Luo is trying to get the government and aid agencies to move faster in addressing the emergence of resistant strains. I am frightened. I heard President Mwanawasa saying government would provide ARVs for a further 100,000 people this year ... I am screaming 'stop', look at what is happening with just 10,000 people on treatment. (Source: UN's IRIN humanitarian information unit

Directly observed treatment for tuberculosis:Less faith, more science would be helpful

Drugs cure tuberculosis. So why does the disease remain in the top 10 causes of global mortality, with 1.8 million deaths a year? Most deaths are in low and middle income countries, where a major challenge is to ensure that drugs are available and people complete the long treatment. The World Health Organization has been tackling the global problem of inadequate tuberculosis control for some years and launched a new programme of integrated care in 1994, called directly observed treatment, short course (DOTS). By using a six month course of drugs, including rifampicin, WHO has mobilised money, people, and systems in countries to tackle the global problem with good progress. Its strategy is divided into five key aspects: political commitment, access to sputum microscopy, short course chemotherapy using direct observation of treatment, an uninterrupted supply of drugs, and a recording and reporting system. There is little argument that resources, drugs, political support, and active management of programmes help improve control of tuberculosis. However, debate continues over whether direct observation of patients taking their treatment by health workers (or their delegates) is essential for successful control. It seems to have arisen out of special programmes in the United States, where direct observation of treatment was part of multifaceted strategies and special studies in Africa. It was at the core of WHO's strategy at launch in 1995, with the director general saying that direct observation by a health worker was the biggest health breakthrough this decade. Direct observation remains core to the current WHO strategy: recently published guidelines say that the key treatment principle of direct observation of treatment remains the same, whichever method of implementation is chosen. The problem with this global policy is that there are currently four carefully conducted trials in Thailand, South Africa, and Pakistan, and these studies show little or no advantage of direct observation over self treatment at home in relation to cure (figure). What is more, these studies were carried out in settings with relatively low cure rates—exactly where better control of tuberculosis is needed. What are the implications for global policy with these research results? We think that WHO and others should reflect on the mismatch between this research evidence and its own beliefs, expressed individually or as consensus statements. Other data are of course important, and this reflection needs also to consider that direct observation costs more than other methods, is paternalistic towards patients, and it can take health workers away from other essential tasks. Some health services may be of such poor quality that patients would prefer not to attend, so potentially direct observation could reduce adherence. Enthusiasts make the world go round, but there is a belief among specialists in tuberculosis that it is unethical not to provide direct observation. This attitude stifles debate and good research into alternatives to direct observation is replaced by semantics. For example, specialists state that direct observation of treatment is more than a mechanical procedure of dropping medicine into a patient's mouth; it is a human bond between a patient and the health worker, to transmit a recognition of the value of treatment success. What would be more helpful is to look at all the strategies to promote adherence. For example, we know that defaulter retrieval action seems to work in some settings; so why not try defaulter actions for self treating patients who do not visit the clinic once a month? What about some good research on staff support and supervision, health education, or various forms of prepackaging? What about peer assisted treatment support? We need a variety of methods to help patients complete their treatment, as well as exploring the circumstances where direct observation will be useful. The energy going into insisting that direct observation is essential and non-negotiable has its own opportunity costs. We believe that there are good arguments for dropping the insistence on direct observation and turning the passion into credible methods for developing, evaluating, and promoting sustainable measures to improve adherence.(Source: BMJ 14 October 2003).

Private prescribing biggest risk for developing world drug resistance

Unless HIV treatment is properly controlled in developing countries, antiretroviral therapy could become useless due to poor practice in the private sector, according to an editorial in the June 21 edition of the British Medical Journal by Ruairi Brugha, a senior lecturer in public health at the London School of Hygiene and Tropical Medicine. He notes that most poor people who suspect they have a sexually transmitted infection seek care in the private sector because of the stigma attached to the disease. However, unpublished research carried out by Oxfam in Tanzania showed that this form of health seeking behaviour was further structured by gender and age, with younger women least likely to seek any sort of treatment, older women and younger men likely to consult traditional healers, and older men most likely to go to private practitioners for antibiotics. There is considerable evidence that private sector prescribing is already a major route to antiretroviral therapy in Africa, and that sub-optimal practice abounds. A study in Zimbabwe carried out in 2000 found that 82% of the pharmacies found to stock HIV drugs carried a single drug, and monotherapy was prescribed to 17% of patients. Poor prescribing practice driven by the cost of the drugs is likely to continue wherever differential pricing excludes the private sector. Whilst generous discounts for public sector and NGO schemes have been highlighted by Indian generic manufacturers, individuals accessing treatment through private practitioners are continuing to pay much higher prices because the drugs available in pharmacies are either branded products or drugs diverted from the public sector. Although the author suggests that the main reason for accessing treatment through private practitioners is to avoid the stigma of attending HIV clinics in public hospitals, the uptake of antiretrovirals through private practitioners must also be related to the delays in making treatment available through the public sector. Research from both Uganda and Senegal shows that the major cause of treatment interruption or discontinuation is lack of money. Donors need to be more active in helping countries to set prescribing and dispensing rules and ensuring compliance with these rules, says Ruairi Bruagh. Work should start with doctors, nurses and trained pharmacists – governments could use NGOs to monitor private providers, although projects that work with the unorganised individual providers are likely to be highly labour intensive. National treatment policies need to take account of the coverage achieved by particular types of providers and the population profile they serve. In small towns with large rural catchment areas, private prescribers may be the only medical practitioners available. Source: 24 June, 2003).

Adherence in Cape Town poor just as good as US and Europe

In South Africa, according to a study to be published next month in AIDS by Dr. Catherine Orrel et al., adherence is not a barrier to successful antiretroviral therapy.  Dr. Orrel Town, found a high rate of adherence in a cohort of their HIV-positive patients initiating treatment, even among those living in extreme poverty. In fact, patients in the study took 93.5% of their prescribed medication, which is as good, if not better, than reported adherence in most of the clinical and observational studies in Europe and in North America. Contrary to the conventional wisdom, socio-economic status had no impact on adherence in the cohort. The team prospectively monitored adherence and evaluated factors predicting poor adherence and virologic failure in 289 patients who enrolled in six antiretroviral trials at between January 1996 and May 2001. Adherence was measured over 48 weeks by pill count. At each visit, patients were given more medication than required and instructed to return all medication bottles and unused pills at the next study visit but patients were not told that the returned pills were to be counted.  Many of the study participants lived in extreme poverty. Forty two percent of the cohort came from households earning less than US$1500 per annum, while a further 20% earned less than US $5500 per year. However in a multivariate analysis, the only factors related to poorer adherence were youth ( age), three-times daily dosing, and home language. Patients whose home language differed from that spoken by most of the hospital staff (English) were less adherent, possibly because instructions on dosing were given in that language. The majority of the cohort spoke Xhosa, the local African language (48%), or Afrikaans (28%), but this was unrelated to socio-economic status.  Overall, sixty three percent of the patients maintained adherence of 90% to the prescribed tablets. Adherence was significantly associated with the reduction in viral load at 48 weeks. Of those that reached 48 weeks of therapy (n = 242), 66.1% had a viral load of < 400 copies/ml. This included 70.9% of those on triple therapy (45 patients in the study had been given dual nucleoside analog therapy). Poor adherence, being assigned to a dual nucleoside analog or three-times daily regimen and having a high baseline viral load were all independently associated with incomplete viral suppression. These factors have also been associated to poor responses in developed countries.  The rate of adherence and viral suppression was similar to or better than that reported in developed countries where patients on similar regimens take about 70% of their HIV antiretroviral medications and the rate of viral load suppression is around 50%. The high proportion of adherence in the study is particularly noteworthy because there was no dedicated adherence counselling service, structured adherence support or formal adherence intervention as part of treatment. The patients only had access to the trial site for one to two hours every two or three months and there were no off-site visits by health care staff to encourage adherence.  There may be some selection bias in their study patients had to be highly motivated to get into a trial, and given the scarcity of anti-HIV treatment in South Africa doctors may have more motivated to enroll patients they felt would closely adhere to treatment. The high rate of adherence may be attributed to limited access to antiretroviral therapy in South Africa. There’s an element of desperation for people who know that they are very fortunate to be in a program offering free antiretroviral treatment. Also a number of these patients have been unwell, and have then responded to treatment. These findings dispute the essentially unsubstantiated view that sub-Saharan Africans are unable to adhere to antiretroviral treatment. (Attaran A, Washington Post 2001; June 15). But the data tell a different story: The results indicate that poor patients in sub-Saharan Africa can achieve high rates of adherence and viral suppression even without direct observed therapy or other formal adherence interventions.  But are the results from a semi-urban setting pertinent to rural Africa? To me, if people can access services in their home language, they should do just as well, said Dr. Orrel. The hold-up to implementing effective treatment in Africa, is the infrastructure and resources, it is not the people. (Source: 27 May 2003)

South Africa: Using cellphones to fight TB

Tuberculosis (TB) patients in South Africa now have a new weapon in the fight against the disease - a cellphone. A pilot project in the coastal city of Cape Town is using the text message service on cellphones to remind patients to take their medication, saving the over-stretched public health services time and money. Treatment for the disease, however, is still a problem. TB patients must strictly follow a difficult drug regime of four tablets, five times a week, for six months. Patients end up being resentful of such an oppressive process, project creator Dr David Green, told PlusNews. Up to 300 patients in a local clinic in Cape Town have been receiving a text message on their cellphones reminding them to take their pills. When patients complained that the initial message take your medicine now was too boring, Green added disease information and tips about lifestyle management. The initiative uses technology in a simple, cheap and flexible way: a software application captures the patient's details into a database, a computer server reads the database, and then sends personalised messages to each patient. At a relatively inexpensive of about 12 rands per patient per month for the short message service (SMS) reminder, the local health authority has decided to extend the pilot project to other clinics with high cellphone ownership. Health experts were initially sceptical whether the uptake of cellphone technology was high enough to justify the project. Research into cellphone ownership, however, found that one in three people with TB in the township of Khayelitsha had cell phones. At the clinic where the pilot study was conducted, 71 percent of TB patients had access to a cellphone. Medical experts have cautiously welcomed the project. Its certainly an interesting and novel way to fight a major problem, Dr Karen Weyer, director of the Medical Research Council (MRC) TB Unit, said. But an increase in adherence could only be tested by randomised control trials, she noted. The MRC and the University of Cape Town will embark on trials to compare the effectiveness of the SMS reminder service against the cost of non-compliance to TB treatment. (Soure: IRIN, 14 April, 2003).