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State of the Art
Measuring and understanding
adherence to ART in Resource poor
settings
What is medication adherence?
• degree to which patient’s medicine use
coincides with prescription by health
worker
• Has different dimensions, including doses
missed, adequate timing of medication use,
compliance to additional requirements like
food-intake, non-alcohol use.
• Changes over time
Three approaches to adherence
• Descriptive: to measure non-compliance
• Analytical: define determinants of nonadherence (comparative approach)
• Intervention oriented -- defining problems
in use of medications and seeking solutions
 Beware: authoritative versus empathy
approach
Different methods to measure
adherence
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Self-report in patient interviews
Patient-kept diaries
Semi-structured interviews
Focus group discussions
Projective techniques, including visual analogue
scales
Pill counts
Electronic monitoring
Prescription record reviews
Drug levels in biological fluids
Adherence methods
• Bad news: no gold standard
• Good news: many methods have acceptable
sensitivity and specificity for our purpose
• Mix of methods can be used to increase
validity
Self-report/diaries
PROS
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CONS
Easy to use in resource
• Time-intensive
poor settings
• Influenced by question
Inexpensive
construction and
Can be used to identify
interviewer skill
high and low adherers
• Patient likely to report
Can be used to explore
desirable behavior
why non-adherence occurs
and possible solutions
• Over-estimates use
Semi-structured interviews
PROS
• Depth of understanding
• Unexpected issues can
come up
• Less ‘authoritative’ style,
more empathy possible
• Generates understanding
of reasons for nonadherence and possible
solutions
CONS
• Time consuming
• skilled interviewer
required
• Analysis is demanding
Focus group discussions
PROs
• Inexpensive
• Participants encourage
each other to talk
• Less authoritative
• Provides information on
general patterns of use,
reasons for non-use and
possible solutions
CONS
• Cannot be used to
measure individual
adherence
• Does not quantify
adherence levels
• Requires skilled
moderator
• Analysis challenging
Projective techniques
PROS
• Good to encourage
discussion
• Visual analogues can
indicate adherence
levels
• Inexpensive
CONS
• Underdeveloped
• Difficult to interpret
Pill counts
PROS
• Easy to use
• Inexpensive
• Non-invasive
CONS
• Does not reflect actual
ingestion of drugs
• Participants have to
remember to bring the pill
bottles
• Patients can dump pills to
appear to be good adherers
• Patients may share pills
• Does not measure actual
use patterns on a daily
basis.
Medical/pharmacy records
review
PROS
• Rapid
• Inexpensive
• Large populations
possible
• Non-invasive
CONS
• Often records missing
• No data on patients
who don’t come back
for check-up or refill
• Need permission from
facility
• Limited set of data
collected routinely
Electronic monitoring
PROS
• Can increase validity
of data
• More resistant to
desirability effect
• Provides details on
daily use
CONS
• Does not confirm
ingestion
• Expensive
• Vulnerable to
mechanical problems
• Does not provide data
on medicine sharing
Drugs levels in biological fluids
PROS
• Objective measure
• Recent use verified
• No details on timing
of use
• Data limited to recent
use
• Expensive
• Difficult to manage –
fluids have to be
collected/transported/a
analysed
Mix of methods
• Combine qualitative and quantitative
- Qualitative: measures dimensions and ways of
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and reasons for non-adherence, and can be used to
identify possible solutions
Quantitative measure how often non- adherence
occurs
• Tri-angulate
• Phase methods
• Validate by correlating with health outcomes
Measures of adherence
• Many different ones used in literature
• Definition often not explicit
• Need to be clear about which dimensions of
adherence are being measured, which not
• Should relate to health outcomes
• Be appropriate to the situation
Kinds of adherence measures
• Numerical: 95% or 80% of prescribed in
- 24 hours
- 3 days
- 1 week
- 1 month
• Five point scale: always/mostly used in
accordance with prescription
• Binary: Adherent – Not
• Composite: adding up different dimensions of
adherence
Usually more than one measure
• Analyzed separately
• Analyzed together to increase validity of
measure (includes more dimensions of
validity, relates better to health outcomes)
• But, no analysis of divergences
qualitatively– why do they occur?
Validity
• Relevant dimensions of adherence
measured
• The measures make sense to respondents
• The measures predict relevant outcomes
(viral load/CD4 counts/health outcomes)
Ways to increase validity….
Be non-adherer friendly:
Most people with HIV have many pills to take
at different times during the day. Many
people find it hard to always remember
their pills...
Reliability
• The same is measured across time and
settings
What influences Adherence?
• Treatment related
• Disease state
• Patient ideas, practices
• Social environment
• Health facility
• National policy
 Usually focus is on patient factors – blame the
victim!
 Very few exploratory studies to define which
factors are relevant in specific situations
Treatment related
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Number of pills
Number of times per day
Dosage level
Adverse effects (of each pill)
Characteristics of drug (branded, colour,
administration form)
• Additional requirements, such as food
intake, non-alcohol use
Disease related
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Health state at initiation of therapy
Seriousness of disease over time
Concurrent Depression/fatigue
Concurrent opportunistic infections
requiring additional medication (TB)
• Individual response to therapy (can vary)
Patient ideas
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Trust in health services
Changes in identity related to using ART
Ideas about HIV-causation
Ideas about disease progression
Ideas about efficacy of HIV medications
Ideas about risks of missed doses
Ideas about toxicity of medicines
Tolerance to side/effects
Lack of knowledge on HIV/Medicine use
Patient practices
• Disciplined life-style
• Disclosure of HIV/AIDS status
• Way medicines are used in every-day life,
including at school/work/when traveling
• Forgetfulness, taking drugs and medical
appointments
• Substance abuse
Patient background variables
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Socio-economic status
Gender
Age
Religion
Employment status
Marital status
Number and age of children
Social environment
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Level of community preparedness for treatment
Adherence support mechanisms, if any
Stigma/fear for HIV/AIDS
Discrimination of particular sub-groups of AIDS
patients (drug-users, prostitutes)
Gender-differentials in support to people on
HAART
Levels of employer support
Levels of privacy
Communication channels on HIV/AIDS and
treatment
Health facility structural
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Accessibility
Regularity of supply
Cost of medicines
Range of medicines available
Spatial dimensions, and cleanliness
Workload of staff
Diagnostic facilities
Guidelines
Records present
Health facility processes
• Quality of patient-provider interactions
• Treatment eligibility and choice
• Constellation of care provided
• Monitoring/response treatment outcome
• Adherence support and follow-up
• Respect for privacy and informed consent
• Over and under the counter payment
• Motivation and training of staff
Counseling: information
Info (oral/written) provided on
-How ARVs work
- How to use them
- The need to continue treatment
- What to do if a pill is forgotten
- Which side effects can occur and what to do if
they occur
- (breast) feeding requirements
- when and where to get re-supply
Info understood?
Counseling: interpersonal
• Client treated with respect, and in privacy?
• Clients feel listened to and do they get a
chance to ask questions about the treatments
and the effects on their bodies and their
lives?
National level
• Political commitment to ART scale-up
• Implementation, kinds of ARVs distributed,
supply chain, training, guidelines
• Specifics for adherence support program
• Monitoring and Evaluation
• Health policy maker views on adherence
problems
Challenges
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Be cost-effective
Describe and understand adherence
Allow for comparison
Select appropriate adherence measure
Select appropriate mix of methods
Define feasible sampling strategy
Overcoming sensitivities
Avoid authoritative approach
Conduct good analysis
And identify solutions with stakeholders